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Full text of "Elements of surgery: for the use of students : with plates (Volume 2)"

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OF 



SURGERY: 

FOR 

THE USE OF STUDENTS; 
WITH PLATES. 

BY 

JOHN SYNG DORSEY, M. D. 

PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, 

ONE OF THE SURGEONS TO THE PENNSYLVANIA HOSPITAL, 

AND TO THE PHILADELPHIA ALMS HOUSE, &C. 

IN TWO VOLUMES. 

SECOND EDITION, WITH ADDITIONS. 
VOL. II. 



for want of timely care 

Millions have died of medicable wounds. 

Abmstrono. 



PHILADELPHIA*. 

PUBLISHED BY EDWARD & RICHARD PARKER, No. 178, AND 
BENJAMIN WARNER, No 171, MARKET STREET. £ 

1818. 



A/VNEX 

Suingj QjLin, 



DISTRICT OF PENNSYLVANIA, to wit : 

Be it remembered, That on the twenty-first day of September, in the 
forty-third year of the independence of the United States of America, A. D. 
1818, Edward & Richard Parker, and Benjamin Warner, of the said District, 
have deposited in this office the title of a book, the right whereof they claim 
as proprietors, in' the words following, to wit: 

"Elements of Surgery: for the use of Students; with Plates. By John Syng 
" Dorsey, M. D. Professor of Anatomy in the University of Pennsylvania, 
" one of the Surgeons to the Pennsylvania Hospital, and to the Philadel- 
" phia Alms House, &c. In two volumes. Second Edition, with additions.'* 

In conformity to the act of the congress of the United States entitled, " An 
Act for the Encouragement of Learning, by securing the copies of Maps, Charts, 
and Books, to the authors and proprietors of such copies during tbe times 
therein mentioned." And also to the act, entitled, " An Act supplementary to 
an Act, entided, " An Act for the Encouragement of Learning, by securing the 
copies of Maps, Charts, and Books, to the authors and proprietors of such 
copies during the times therein mentioned," and extending the benefits thereof 
to the arts of designing, engraving, and etching historical and other prints." 

D. CALDWELL, 
Clerk of the District of Pennsylvania. 



CONTENTS OF VOL. H. 



Page 
CHAPTER I. 

Of Scirrhus and Cancer, 1 

Operation, - - - - - 20 

CHAPTER II. 

Of fungus hematodes, - - - ' - -23 

CHAPTER III. 

Of hernia, - - - - - 26 

CHAPTER IV. 

Symptoms of reducible hernia, - - - - 32 

CHAPTER V. 
Symptoms of strangulated hernia, - - 35 

CHAPTER VI. 
Treatment of reducible hernia, - - 42 

CHAPTER VII. 

Treatment of irredttcible hernia, - - - 48 

CHAPTER VIII. 

Treatment of strangulated hernia, - - - 50 

1. Of the taxis, - - - - ib. 

2. Of blood-letting, - - - 53 

3. Of the warm bath, - - ib. 

4. The tobacco clyster, - - 54 

5. Cold applications, - - -55 

6. Opium, - - - ib. 

7. Cathartics, - ib. 
Vol. II. A 



11 CONTENTS. 

Page 
CHATTER IX. 

Of inguinal hernia, - - - - - 59 

Operation, - ' m." ' " 6 ^ 

CHAPTER X. 
Of mortified intestine, . - i , . . 79 

CHAPTER XI. 

Artificial amis, - - - 90 

CHAPTER XII. 

Of femoral hernia, 93 

Operation, - - . - - 103 

CHAPTER XIII. 

Exomphalos, or umbilical hernia, - - - 114 

Operation, - . - - -117 

CHAPTER XIV. 

Of ventral hernia, - - _ _ - 123 

CHAPTER XV. 
Of hernia congenita, - - - - 124 

CHAPTER XVI. 

Of hydrocele, - - - - - 126 

Treatment., - - - _ - 130 

Of the palliative cure, - - - ib. 

Of the radical cure, - 132 

CHAPTER XVII. 

Of hematocele, - - - - -137 

CHAPTER XVIII. 

Of varicocele and circocele, - - - - 138 

CHAPTER XIX. 

Of strictures in the urethra, - - - - 140 

Treatment, - 144 

CHAPTER XX. 

Of fistula in perineo, - - - . -151 



CONTENTS. 1U 

Page 

CHAPTER XXI. 

Of retention of urine, - - - -155 

CHAPTER XXII. 

Of tapping the bladder, - ■ - - - 166 

Of the puncture above the pubes, - - ib. 

Of the puncture through the rectum, - 168 

CHAPTER XXIII. 

Of stone in the bladder, - - - - 170 
Operation, ----- 176 

CHAPTER XXIV. 

Of fistula in ano, - - - - - 186 

Treatment, - - - - - 187 

CHAPTER XXV. 

Of hemorrhoids, - - - - -191 

CHAPTER XXVI. 

Of prolapsus ani, - - - - 194 

CHAPTER XXVII. 

Of aneurism, - - - - - 197 

Treatment of true aneurism, - - 201 

Popliteal aneurism* - 204 

Femoral and inguinal aneurism, - - 206 

Aneurism of the carotid artery, - - 212 

Aneurism of the axillary artery, - . 220 

Tying the arteria innominata, - - 225 
Tying the aorta, .... 226 

CHAPTER XXVIII. 

Of false aneurisms, - - - - -251 

CHAPTER XXIX. 

Of mammary abscess, - - - - 264 

CHAPTER XXX. 

Mscess of the hip joint, - 266 

Treatment, - 268 



ir CONTENTS. 



Page 



CHAPTER XXXI. 

Lumbar, or psoas abscess , - - - 270 

Treatment, ----- 271 

CHAPTER XXXII. 

Of curved spine, - - - - - 274 

CHAPTER XXXIII. 

Of paronychia, or whitlow, - - . 892 

Treatment, - 293 

CHAPTER XXXIV. 
Of amputation of the limbs, - 295 

CHAPTER XXXV. 

Amputation of the thigh, - - - - 299 

CHAPTER XXXVI. 

Amputation of the leg, - 304 

CHAPTER XXXVII. 
Amputation of the arm, - 307 

CHAPTER XXXVIII. 
Of amputation at the shoulder joint, - 308 

CHAPTER XXXIX. 
Amputation at the hip joint, - - - - 321 

CHAPTER XL. 
Amputation of the fingers and toes, - - - 335 

CHAPTER XLI. 
Of hemorrhage after amputation, - . - - 336 

CHAPTER XLII. 
Of spasms of the stump, - 340 

CHAPTER XLIII. 
Extirpation of tumours, - - - - 341 

CHAPTER XLIV. 
Of warts and corns, ----- 346 



CONTENTS. V 

Page 
CHAPTER XLV. 

Of the inverted toe nail, - - . . 348 

CHAPTER XLVI. 
Of paracentesis abdominis, - - - - 350 

CHAPTER XLVII. 

Paracentesis thoracis, - - - 353 

CHAPTER XLVIII. 

Of blood letting, .... - 355 

Plebotomy, ----- ib. 

Arteriotomy, - - - - 358 

Cupping, ----- ib. 

Leeching, ----- 359 

CHAPTER XLIX. 
Of ulcers, ------ 360 

CHAPTER L. 

Of inflamed ulcers, - - - - - 370 

CHAPTER LI. 
The fungous ulcer t ----- 372 

CHAPTER LII. 

Of ulcers in cedamatous limbs, - - - 374 

CHAPTER LIII. 
TJie sloughing ulcer, - - - - 376 

CHAPTER LIV. 
Of indolent ulcers, - - - - -378 

CHAPTER LV. 
The carious ulcer, - - - - 384 

CHAPTER LVI. 
Ulcers attended with varicose veins, - - 386 



VI CONTENTS. 

Page 
CHAPTER LVII. 

Ulcers attended with specific diseased actions, - - 394 

1. Of those ulcers which yield to mercury, ib. 

2. Of ulcers which yield to the different prepa- 
rations of the conium macula* urn, or hemlock, 396 

3. Of ulcers which yield to the application of 

salt water, .... 398 

4. Of ulcers which yield to the use of the argen- 

tum nitratum, - 399 

5. Of ulcers that yield to the use of arsenic, 403 

CHAPTER LVIII. 
Of caries, --____ 408 
Treatment, - - - - -412 

CHAPTER LIX. 

Of necrosis, - - . _ _ -417 

Treatment, - 425 

CHAPTER LX. 

Of setons and issues, _ - - - 428 

CHAPTER LXL 

Of mat-formations, - - - _ _ 432 

Of hare-lip, - - - - . ib. 

CHAPTER LXII. 

Of clubfoot, ----- 436 

CHAPTER LXIII. 

Of spina bifida, - 44^ 

CHAPTER LXIV. 

Of imperforate anus, - _ . .443 

CHAPTER LXV. 
Of imperforate vagina, - 44S 

CHAPTER LXVI. 
Of the Cwsarean operation, .... 4 »- 5 



CONTENTS. 


Vll 


CHAPTER LXVII. 


Page 


On the division of the symphysis pubis* 


460 


CHAPTER LXVIII. 




Of prolapsus uteris - 
Treatment, - 


463 
464 


CHAPTER LXIX. 




Of bandages, - 


466 


CHAPTER LXX. 




Of opening dead bodies, - 


470 



ELEMENTS 



OF 



SURGERY. 

CHAPTER I. 

Of Scirrhus and Cancer. 

A PAINFUL, incurable ulcer, results from the suppu- 
ration of certain indurated tumours. The tumours are 
denominated scirrhous ; the ulcer is called cancer. These 
definitions (if they deserve the name) are by no means 
satisfactory, but it is not easy to describe in a few 
words, those tumours which will certainly produce 
cancer, nor those ulcers which are decidedly can- 
cerous, except in particular cases. The truth of this 
remark will not be doubted by any person who will take 
the trouble to consult the different surgical writings 
which contain histories of cancerous complaints. There 
is perhaps no subject on v/hich accurate discrimination 
is of more importance, and none in which it is made 
with more difficulty. 

Scirrhus and cancer occur in every part of the body, 
glandular parts are however much more liable to the 
disease than others. 

A true scirrhus, before it degenerates into a cancer- 
ous sore, is hard and unequal on its surface, slightly 
sensible to the touch, not tending to suppuration, and en- 
Vol. II. B 



2 ELEMENTS OF SURGERY. 

larging very slowly in its commencement ; " but at length 
assuming a more active form, it is surrounded with 
superficial varicose veins, it becomes more painful, 
and changes the texture of the adjacent cellular mem- 
brane or cuticular covering, to which it frequently ad- 
heres : the skin will, in this advanced period, sometimes 
be discoloured, and puckered or retracted, especially in 
the female breast f perhaps attended with a degree of 
softness or fluctuation in some part of the tumour, with 
shooting pains in its neighbourhood ; and at last break- 
ing into a malignant sore, with fungous flesh, and re- 
troverted edges ; it is named an open cancer." 

The progress of the disease is not always equally ra- 
pid ; in some cases a scirrhous tumour remains for many 
years indolent, and in other instances it ulcerates in a 
few weeks after it is first noticed. 

It is always- satisfactory to ascertain, if possible, the 
nature of a tumour after it is removed. The appearance 
of a scirrhous tumour has been very well described by 
Mr. Home. " When a section is made of such a tu- 
mour in an early stage, provided the structure can be 
seen to advantage, it puts on the following appearance : 
the centre is more compact, harder to the feel, and has a 
more uniform texture than the rest of the tumour ; and is 
nearly of the consistence of cartilage. This middle part 
does not exceed the size of a silver penny : and from 
this, in every direction, like rays, arc seen ligamentous 
bands of a white colour, and very narrow ; looking, in 
the section like so many extremely irregular lines, pass- 
ing to the circumference of the tumour, which is blend- 
ed with the substance of the surrounding gland. In the 
interstices, between these bands, the substance is differ- 
ent and becomes less compact towards the outer edge. 
On a more minute examination, transverse ligamentous 
bands of a fainter appearance, form a kind of net-work, 



ELEMENTS OF SURGERY". 3 

in the mashes of which the new-formed substance is in- 
closed. This structure accords with what Dr. Bailley 
describes to be the case, in cancerous diseases of the 
stomach and uterus. 

" In a further advanced stage of the tumour, the whole 
of the diseased part has a more uniform structurs ; no 
central point can be distinguished ; the external edge is 
more defined, and distinct from the surrounding gland : 
and the ligamentous bands, in different directions, art- 
very apparent, but do not follow any cpurse that can be 
traced. 

"When the tumour has advanced to what may be called 
cancerous suppuration, which, however, does not always 
happen in the centre, before it has approached the skin, 
and formed an external sore ; it then exhibits an appear- 
ance totally different from what has been described. In 
the centre is a small irregular cavity, filled with a bloody 
fluid, the edges of which are ulcerated, jagged, and 
spongy. Beyond these, there is a radiated appearance 
of ligamentous bands, diverging towards the circumfer- 
ence ; but, the tumour near the circumference is more 
compact, and is made up of distinct portions, each of 
which has a centre, surrounded by ligamentous bands, 
in concentric circles. 

" In some instances, the scirrhus has no appearance 
of suppuration, or ulceration in the centre, but consists 
of a cyst, filled with a transparent fluid, and a fungous 
excrescence, projecting into this cavity, the lining of 
which is smooth and polished. When a large hydatid 
of this kind occurs, a number of very small ones have 
been found, in different parts of the same tumour ; and, 
in other cases, there are many very small ones of the 
size of a pin's head, without a large one. These hyda- 
tids are certainly by no means, sufficiently frequent in 



4 ELEMENTS OF SURGERY. 

their occurrence to admit of their forming any part of 
the character of a cancerous tumour." 

In some cases cysts exist of various forms and sizes, 
and in different parts of the tumour ; a late writer (Dr. 
Adams) pronounces these to be living hydatids. When 
tumours are extirpated exhibiting these appearances, we 
may rest assured that they would never have been dis- 
cussed and in all probability would have advanced to 
the state of true and malignant cancer. 

We are not however always able to prediet what tu- 
mours will become so, and what particular tumours may 
remain unsuspected. Mr. Home with great and com- 
mendable candour remarks, that so much does the 
same disease differ in its appearance in different pa- 
tients, from the almost endless peculiarities of their con- 
stitutions, by which every part of their bodies must be 
more or less influenced, that it is not possible in prac- 
tice to distinguish, in all cases, between cancerous and 
scrofulous tumours, after they have advanced to a cer- 
tain stage, and he confesses that he has in many in- 
stances mistaken the one for the other, and has removed 
by operation tumours, which at the time had the appear- 
ance of being cancerous, but which upon examination 
after their removal were found of a scrofulous nature ; 
and, on the other hand, he has neglected to remove tu- 
mours, from circumstances making it probable that they 
were scrofulous, which afterwards became cancerous 
and destroyed the patient. 

Although surgeons generally have not confessed their 
mistakes, yet the immense disparity which appears in 
the record of their successes establishes the fact that 
Mr. Home has not been singular in confounding can- 
cerous with other diseases. Mr. Nooth, for example, 
declares, that in one hundred and two cases in which 
he extirpated scirrhus tumours, every patient remained 



ELEMENTS OF SURGERY. 5 

free from a return of the complaint. Dr. Monro, on the 
contrary states, that of sixty cancers which lie had seen 
extirpated, only four remained free of the disease for 
two years, and these afterwards became cancerous. 

Mr. Hill, in his Cases of Surgery says, he had ope- 
rated on eighty-eight genuine cancers, all ulcerated ex- 
cept four, and all his patients except two recovered of the 
operation ; ten however had the disease afterwards in 
other places. 

Among the diseases resembling cancer, Mr. Home 
describes one by which parts of a glandular nature are 
often attacked, as the alse of the nose, the os tincae and 
the glans penis ; — this differs from cancer in not contami- 
nating the surrounding parts, and in not affecting the 
absorbent glands, nor the skin at a distance ; it is pro- 
perly speaking an eating sore which is uniformly pro- 
gressive ; whereas in cancer, after the sore has made 
Some progress, a ridge is formed upon the margin, and 
the ulceration no longer takes that direction. It also 
differs from cancer in admitting of a cure in many in- 
stances, and under different modes of treatment. 

Cancer has by many writers been considered as a 
contagious disease, of this opinion there is however no 
well grounded proof. Some facts have been recorded 
which prove disease to have resulted from the applica- 
tion of cancerous matter to sound parts, but no instance 
has been produced in which a cancerous sore has been 
the consequence. Mr. Pearson who has treated this sub- 
ject with great ingenuity, remarks, that " virulence and 
contagion are very different things ; the bite of a viper, 
or the sting of a scorpion, may poison a part by the ma- 
lignant quality of the venom that ts injected, without 
communicating a contagious disease, and the fluid taken 
from a pustule or an ulcer, may erode a part by its die- 



6 ELEMENTS OF SURGERY. 

mical qualities, and yet the matter formed by this new 
sore shall not possess similar properties with that which 
produced the ulceration. It is not sufficient therefore to 
assert, that the fluid of a cancerous sore occasioned an 
ulcer in a sound person; it ought to be proved that the 
ulcer thus produced was truly cancerous." 

Cancer has also been considered an hereditary dis- 
ease. Mr. Home is inclined to believe that a predispo- 
sition to cancer, depending on local peculiarities of struc- 
ture, may be transmitted from parents to, their descen- 
dants, and in this sense of the word, the disease is no 
doubt hereditary. This idea originated with Mr. Hunt*, 
er who illustrated it by observing that of fifty persons 
who may receive similar accidents in glandular parts, 
not more than one or two will be afflicted with subse- 
quent cancers. 

The disease occurs at almost every age ; it is most 
frequent, however, in advanced life. The period of 
the cessation of the menses in women, is supposed very 
obnoxious to cancer. Dionis says that he saw very 
many women in the nunneries of France, afflicted with 
cancer, and that by much the greater part were between 
the ages of forty five and fifty, and that in those who 
had cancers at an earlier period the catamenia were 
either very irregular or had been entirely obstructed. 

The female mamma is perhaps the most frequent seat 
of cancerous affections, and as this part is liable to se- 
veral other diseases, it may not be improper to describe 
some, with which cancer has often been confounded. 

In some cases the whole substance of the mamma will 
enlarge gradually till it acquires an enormous size, with- 
out very acute pain ; the patient complains of great ten- 
derness and soreness, but the greatest inconvenience is 
derived from the bulk and weight of the tumour ; some- 
times the swelling is attended with considerable heat 



ELEMENTS OF StfRGERY. < 

and redness of the part and symptomatic fever. The 
skin of the breast in many instances, is not at all disco - 
loured, in some it is reddened. This complaint is not 
peculiar to married women but occurs also in the sin- 
gle. 

In these cases copious depletion, and antiphlogistic 
measures, local and general, must be used, cupping, 
bleeding, purging, low diet, &c. They generally suc- 
ceed, but even if they do not leave the breast of its usual 
size, the swelling has no cancerous tendency and re- 
mains without any inconvenience being sustained, but 
from its bulk and weight. These, however, are in them- 
selves serious evils, and the breast is sometimes removed, 
to relieve the patient from them. Under such circum- 
stances no doubt of a recovery need exist. 

A chronic inflammation sometimes occurs in the breast, 
producing considerable deep seated pain ; — a tumour is 
felt very hard and deep in the substance of the mam- 
ma ; — heat and throbbing are perceived, and sometimes 
shooting pains through the diseased part ; — the skin ge- 
nerally retains its natural appearance, but if the disease 
advances to suppuration it becomes red and sore ; — it at- 
tacks young women chiefly, and without any exciting 
cause being evident. Very copious depletion will ge- 
nerally prevent suppuration and relieve the patient. 
Local and general bleeding with the usual antiphlogis- 
tic means are to be tried, and if any hardness remain 
after their use, cicuta and mercury may be administer- 
ed — and these generally produce a speedy absorption of 
the tumour. 

The breasts of females like every other part of the 
body are liable to scrofula. Scrofulous tumours have 
been described by the ancient writers, under the name 
of spurious scirrhi : sometimes they commence so gra- 



8 ELEMENTS OF SURGERY. 

dually as to assume many of the appearances of scirrhus, 
but in general they may be distinguished. 

Where the skin only is affected no danger of scirrhus 
exists. In scrofula the disease is more diffused, the 
skin soon becomes red, and the symptoms of inflamma- 
tion are more rapid, and sometimes terminate very spee- 
dily in suppuration. 

Where a number of tumours exist in the breast we 
may pronounce them in most cases to be certainly scro- 
fulous. 

Hydatids are sometimes found to constitute the tu- 
mours, which are removed as scirrhi, these are not rea- 
dily distinguished, and when extirpated there is no dan- 
ger of a return of disease. 

Notwithstanding this, it must be confessed that it is in 
many cases very difficult, nay in the present state of sur- 
gical knowledge, absolutely impossible to pronounce with 
certainty, what cases are scirrhus and what scrofulous. 
This should induce the surgeon in doubtful cases to 
choose the safest side, and to extirpate those tumours 
which have a suspicious aspect. 

It is not necessary to say much of any remedy for 
cancer except the extirpation of the diseased parts. It 
will be sufficient to state that certain discutient, corro- 
sive, and narcotic medicines, from the vegetable, ani- 
mal, and mineral kingdoms have been employed, most 
of which have had a temporary reputation but do not at 
this time retain the confidence of medical men. The use 
of narcotics is proper with a view to alleviate pain, and 
corrosive medicines are sometimes employed to destroy 
fungous flesh from the surface of the sore : discutient 
applications, as has been already stated, have no effect 
upon genuine cancer. 

The internal use of arsenic has lost its character as a 
remedy for cancer, and preparations of iron, a fashion- 



ELEMENTS OF SURGERY. 9 

able substitute, lately introduced by Mr. Carmichael, 
will no doubt speedily share the same fate. 

The best mode of abating the pain of cancer is by a 
very abstemious diet ; Mr. Pearson recommends a diet 
so low, as barely to support life, such as barley water, 
tea, &c. A milk and vegetable diet has relieved the 
agonies of many cancerous patients. 

As local applications I subjoin the following list from 
the article Cancer in Rees' Cyclopedia. — Fresh bruised 
hemlock leaves. — Scraped young carrots. — The ferment- 
ing poultice. — Finely levigated chalk. — Powdered char- 
coal. — Carbonic acid gas. — A watery solution of opium. 
— Liquid tar, or tar- water. The internal remedies which 
have been most beneficial are — Very small and long 
continued doses of arsenic. — Liberal doses of cicuta. 
— The free use of opium. — Belladonna. — Solanum. — 
Martial flowers. — Gorosive sublimate. — The juice of 
clivers or goose-grass. But neither the external nor in- 
ternal remedies, however apparently useful for a time, 
can be in the least depended on for the cure of a ge- 
nuine confirmed cancer. 

Where the operation is concluded on, it should be 
performed early, for authors agree that where the poison 
is absolutely formed, and the neighbouring parts conta- 
minated, the prospect of success is greatly diminished, 
and in cancer of the breast where the glands of the axilla 
are affected, Mr. Cline and Mr. Home declare it too 
late to perform the operation with any " assurance of 
success."* — But experience warrants us in differing from 
the gentlemen whose names have been mentioned. In 
this country Dr. Physick has extirpated the breast in se- 

* It is here necessary to state that the glands of the axilla may be enlarged 
from sympathy, in which case they vary in size at different times ; where they 
are contaminated by the poison they gradually and uniformly increase, and. the 
knife is often useless. To the latter case th# present observations refer. 

Vol. IT C 



10 ELEMENTS OF SURGERY. 

veral instances in which the glands of the axilla have 
been affected, and he has applied ligatures so as to eradi- 
cate these also. In some cases the disease has returned, 
but in several he has had the satisfaction to believe that 
life has been prolonged by the operation, and at the ex- 
piration of several years his patients remain free from all 

disease. 

Two methods of extirpating tumours are in use. The 
knife and caustic. The advantages of the former are very 
great ; the surgeon has it in his power to remove the 
whole of the diseased parts from the healthy, and the 
diseased may be discriminated in the course of his inci- 
sions, but with caustic it is impossible to judge precisely 
what parts will be removed If, however, from the great 
terror of surgical operations which exists in some patients, 
or from any other cause, the caustic be preferred, Mr. 
Home recommends a preparation of equal parts of white 
arsenic and sulphur. 

When the knife is to be used, the following are en- 
couraging circumstances : — First, Where the diseased 
parts are so situated as that they may be removed with- 
out wounding any large blood-vessels and nerves, and 
where the whole of them may be completely eradicated. 
Second, Where the disease has resulted from accident, 
and has not occurred spontaneously. Third, Where 
the patient is in good general health. Fourth, Where 
the disease is slow in its progress, and has not contami- 
nated the surrounding parts. 

OF THE EXTIRPATION OF CANCEROUS BREASTS. 

Previously to the operation, the parts should be ex- 
amined with great attention, in order to ascertain the ex- 
tent of the disease, and the surgeon in this, as in every 
operation for the removal of cancerous parts, should not 



ELEMENTS OF SURGERY. 11 

merely cut away the parts already indurated and diseas- 
ed, but likewise some portion of the surrounding sub- 
stance in which a diseased disposition may probably 
have been excited. 

In performing the operation the patient is to be seated 
in a chair in a good light. If the skin be sound, and a 
tumour only exists in the breast, a straight incision may 
be made through it, and the diseased part dissected out. 
But if it is determined that a part of the skin should be 
removed with the tumour, two incisions are to be made, 
forming an oval figure between them, in which all the 
skin to be taken away, is included ; and as dividing the 
skin is the most painful part of the operation, both these 
incisions should be completed before any thing else is 
done ; and the lower part of the skin should be divided 
first, since, if a wound is made in the upper part, the 
effused blood covers the skin below, and prevents the 
surgeon from seeing accurately where the second incision 
ought to be made. These incisions should be nearly in 
the direction of the fibres of the pectoral muscle. If the 
glands in the axilla are diseased, the incision should be 
high enough in that direction to allow of their removal 
with the tumour. The best way to do this is to dissect 
the diseased breast out first, and then to dissect upwards, 
without cutting it off, and detach the hardened lympha- 
tics and glands in the arm pit which will be pulled down 
by the weight of the tumour, and thus the operator will 
be enabled to extirpate them more conveniently. As 
soon as the fingers can be passed above the indurated 
axillary glands, they are to be cut off, but before this, the 
cellular membrane connecting them above is to be tied by 
a firm ligature, to prevent hemorrhage from any vessel 
that may be contained in it. This direction is of the 
utmost importance ; for if it be neglected, the vessels 
will retract so high into the axilla, that the surgeon will 



12 ELEMENTS OF SURGERY. 

be unable to secure their orifices. When the tumour is 
taken out, the bleeding vessels should very carefully be 
tied, and the edges of the Wound brought into contact, 
and kept so by adhesive plasters and compresses, so that 
as much as possible of the wound may unite by the first 
intention. The ligatures are to be left out at the angles 
of the wound. 

Scirrhous tumours sometimes form in the neck, and 
when they are deeply seated great hazard attends their 
removal ; in general, however, the tumours found in the 
neck are of a scrofulous, and not a cancerous nature. 
Mr. Pearson denies that the absorbent glands, which are 
found indurated under the lower jaw, are in any case 
scirrhous, unless they have been contaminated by can- 
cerous ulcers of the lip, tongue, or fauces. In some ca- 
ses it is necessary to remove them, even when they are 
evidently not scirrhus, on account of their impeding the 
functions of respiration and deglutition, or because they 
compress the blood-vessels of the neck : no unpleasant 
consequences result from their extirpation, and the chief 
caution necessary is to avoid wounding the vessels. 

The parotid and submaxillary glands are often 
the seat of true cancer. The nose and other parts of 
the face are also occasionally attacked by cancerous ul- 
cers. The term noli me tangere has been applied to 
some of these complaints. The ulcers described by dif- 
ferent writers under this name, are so very various, that 
it is certain they have attached no precise idea to their 
definition. One author describes it as a disease of the 
nose exclusively.* Others have seen it on the legs and 
arms. The term lupus has been attached to it when in 
these latter situations. I am persuaded that the disease 
recently described by Mr. Hey and Mr. Burns under 

• Cooper. 



ELEMENTS OF SURGERY. 13 

the titles of fungus hematodes, and spongoid inflam- 
mation, are of the same nature, as many of the cases de- 
nominated by the older writers noli me tangere. 

In many of these ulcers on the face, as well as in 
other situations, fungous granulations arise to a very great 
height, and their growth is in some cases so rapid that 
Wiseman asserts it to be obvious to the eye. The ap- 
plication of caustic has proved successful in some cases ; 
where the whole of the diseased parts can lie completely 
extirpated by the knife, they should be removed. In 
general, however, when the parotid gland is affected, 
this cannot be done, and the attempt will only aggravate 
the disease, and hasten its progress. 

Cancer of the tongue is unusual, but is occasional- 
ly met with ; Mr. Home has seen two cases of it, one of 
which occurred in a gentleman between fifty and sixty 
years of age. Upon dissection after death, a large gland 
was found under the coronoid process of the lower jaw, 
weighing two ounces and a half, all the lymphatics in 
the vicinity were diseased, and the cancer extended to 
the pharynx. As cancerous ulcers are probably in the 
present state of our knowledge incurable, and always 
unless the diseased parts are removed, terminate fatally, 
we should not hesitate to extirpate the tongue when af- 
fected with cancer ; the mode of effecting this has al- 
ready been described, it is however proper to add, that 
from the testimony of Desault and others, we learn, that 
patients in whom great portions of this important organ 
have been removed, have not entirely lost the power of 
speaking intelligibly. 

The rectum is sometimes affected with scirrhus and 
cancer, no cases of recovery from this complaint are re- 
corded. Opiate clysters, and opium, introduced in form 



14 ELEMENTS OF SURGERY. 

of pills into the rectum give great relief. The ulcera- 
tion, in a case described by Mr. Home, extended through 
the bladder, and faeces were voided with the urine. 

The tunica vaginalis testis has been found can- 
cerous. Mr. Hunter once extirpated nearly the whole 
of it in a scirrhus state. 

The bladder is liable to cancer. Gooch relates a 
case in which the bladder of a boy, only eight years of 
age, was affected with scirrhus, — he died, — and upon 
examination, the bladder was found thickened and con- 
tracted, so as to resemble " the gizzard of a fowl/' and 
was incapable of containing more than a spoonful of 
urine ; it contained two calculi. 

Cancer of the penis is not unfrequent, it commences 
usually with a wart or tubercle on the prepuce, frenum, 
or glands. This often remains quiescent for many 
years, but if irritated becomes painful, increases in bulk, 
and attains in a short time a very large size. Ulceration 
takes place attended with a discharge of fetid sanies. 
When the ulcer continues long, the urethra is exposed 
and fistulous openings form, through which the urine 
flows, and the disease is aggravated. The glands in the 
groin and upon the ossa pubis are affected, and the dis- 
ease extends in their course. To distinguish venereal 
warts from those tending to cancer is in general not diffi- 
cult ; and when the cancer exists, the penis should be 
removed before contamination is gone too far. 

Mr. Hey has published seven cases of cancer penis, 
in six of which the patients had a natural phymosis. He 
remarks that the occurrence is extraordinary if it have no 
connection with the disease. In six of these cases Mr 



ELEMENTS OF SURGERY. 15 

Hey effected a cure by amputation. In the seventh the 
disease recurred. 

The amputation of the penis is to be performed when- 
ever the disease is evidently of a cancerous nature. The 
operation is very simple, a circular incision is to be made 
through the skin, with a bistoury at some distance (half 
an inch if practicable) from the diseased part, the skin is 
to be drawn back a little, and the body of the penis cut 
through with one even stroke of the knife, at the part to 
which the skin has been retracted. The bleeding ves- 
sels are then to be secured with ligatures. Three prin- 
cipal vessels are to be looked for, one on the dorsum pe- 
nis, and one in each corpus cavernosum. An elastic 
catheter is now to be introduced into the urethra, and 
the skin drawn forward so as to cover the stump, and 
secured in this situation with strips of adhesive plaster. 
The catheter is objected to by Mr. Pearson, but in some 
cases where it has been omitted the external aperture of 
the urethra has been greatly contracted by the healing 
of the wound. After the first dressing is removed, a 
pledgit of simple cerate is to be applied and renewed as 
often as may be necessary. 

Mr. Hey says that in amputating the penis he has 
found great advantage from having wrapped some tape 
round the sound part 5 in this way he was enabled ta 
divide the integuments more easily and correctly, and he 
was also furnished with a useful kind of tourniquet, 
which secured the divided vessels from bleeding, till he 
was prepared to take them up with the tenaculum and 
ligature. He remarks, that " it requires great care to se- 
cure the larger arteries, as they are apt to shrink and 
conceal themselves under the loose integuments to which 
they have no strong attachment." 

Cancer op the uterus though a rare, is a deplorable 



16 ELEMENTS OF SURGERY. 

and hopeless case. The use of all irritating injections 
is improper. The greatest benefit will be derived from 
a strict adherence to a very low diet. Pain is to be re- 
lieved by the administration of opium. I have relieved 
the pain in one case very considerably by injections of 
warm barley water thrown up the vagina. An aqueous 
infusion of opium may be substituted if the barley water 
should not answer the purpose. Anodyne enemata are 
also very often necessary. 

The scirrhous testicle is a frequent disease, and 
sooner or later ends in cancer unless extirpated. Mr. 
Potts' description of this complaint is extremely accu- 
rate (i When the testicle becomes enlarged in size, — 
hardened in texture, — craggy and unequal on its sur- 
face, — painful on being handled, — attended with irregu- 
lar pains shooting up the groin into the back, and this 
without any previous inflammation, disease, or external 
violence, the testicle is said to be affected with a scir- 
rhous" — he further adds that in such cases early castra- 
tion may be recommended and practised by every honest 
and judicious surgeon. 

If this is neglected — hectic supervenes — ulceration 
takes place — a fungus shoots out from the surface of the 
testicle, and the patient falls a victim to the neglect of 
his case. 

There are several diseases of the testis comprized 
under the general name of sarcocele which it is impor- 
tant to distinguish from cancer. Hernia humoralis in 
its recent stage cannot be mistaken for scirrhus, but 
after the acute symptoms subside a great degree of indu- 
ration remains, with an enlargement and unequal sur- 
face. The epididimis often continues hardened for 
some months, but generally we are able to produce reso- 
lution, or if the testicle even suppurates the abscess very 



ELEMENTS OF SURGERY. 17 

readily heals without occasioning much general disease. 
None of the symptoms of scirrhus exist in this case, as 
the pain ceases and the hardness subsides. 

A scrofulous tumour of the testis is described by 
writers which exists either in the spermatic cord, the 
epididymis, or the body of the testicle. This may also be 
distinguished. Here the inflammation runs higher, and 
comes on more rapidly than in cancer, the system sym- 
pathizes, and fever is produced, the pain is very obtuse, 
and rather deserves the name of soreness than of pain. 
This complaint gets well very readily in some cases, and 
is reproduced by exposure to cold or intemperance, and 
suppuration, with collections of matter take place in va- 
rious parts of the scrotum. 

A disease described by Mr. Abernethy under the 
name of medullary sarcoma, may not improperly be no- 
ticed here. It has been called soft cancer, and appears 
to be as malignant and incurable as that which has al- 
ready been described. The following case from Aber- 
nethy's writings will convey a clear history of the dis- 
ease. 

" A tall, thin, healthy-looking man, of about forty 
years of age, had, about fifteen years before, a swelled 
testicle from a gonorrhoea; the epididymis remained in- 
durated. Six years afterwards it became enlarged, and 
a hydrocele at the same time formed. Half a pint of 
water was discharged by a puncture, but inflammation 
succeeded the operation, and tlie testis became very 
large. An abscess formed, and burst in the front of the 
scrotum, and the testis subsided in some degree. Mer- 
cury was employed to reduce it, but without effect. The 
part, however, was indolent, and gave the patient no 
trouble but from its bulk. 

" About a year afterwards, a gland enlarged in the 
left groin (the same side as the testis :) another thenbe- 
Vol. IT D 



18 ELEMENTS OF SURGERY. 

came swollen in the right groin, and, in the course of 
two years, several glands in each groin had obtained a 
very considerable magnitude. At this period, he was' 
admitted into St. Bartholomew's Hospital, under the 
care of Mr. Long. The testis was at this time, between 
four and five inches in length, and about three in breadth; 
it resembled its natural form and was indolent in its dis- 
position. The spermatic cord was thickened, but not 
much indurated. Four or five glands were enlarged in 
the groin on both sides ; each of which was of the size 
of a very large orange ; and when observed together, 
they formed a tumour of very uncommon shape and mag- 
nitude. 

" They gradually increased in size for several months, 
till at last the skin appeared as if unable to contain them 
any longer. It becames thin, inflamed, and ulcerated, 
first in the left groin, and thus exposed one of the most 
prominent tumours. The exposed tumour inflamed and 
sloughed progressively, till it entirely came away. As 
the sloughing exposed its vessels, which were large, 
they bled profusely, in so much that the students endea- 
voured, but in vain, to secure them by ligatures : for the 
substance of the tumour was cut through, and torn away 
in the attempt. Pressure by the finger, continued for 
some time, was the only eifectual mode of restraining 
this hemorrhage. 

" The loss of one gland relieved the distended skin, 
which had only ulcerated in the most prominent part of 
the tumour, and had not become diseased. It now lost 
its inflamed aspect ; granulations formed, and a cicatrix 
took place. In the opposite groin a similar occurrence 
happened. One gland, exposed by the ulceration of the 
skin sloughed out, being attended by the circumstances 
just recited. However, before the skin cicatrized, ulce- 
ration had again taken place in the right groin, in con- 



ELEMENTS OF SURGERY. 19 

sequence of the great distension of the skin from the 
growth of the tumour, and sloughing had begun in the 
tumour, when the patient, whose vital powers had long 
been greatly exhausted, died." 

Mr. Ramsden of London has recently published some 
very valuable observations on certain diseases of the tes- 
ticle. In the preface to this work he attempts to prove, 
that genuine cancer of the testicle is extremely rare ; that 
most of the cases of sarcocele which have been mistaken 
for it, arise from latent irritation in the urethra ; he does 
not deny that the testicle is liable to scirrhus and to 
sarcocele, both of which may lead to an untractable state 
of ulceration, but he believes that "the malignancy of the 
ulcerative stage of true scirrhus in the testicle, does not, 
as has been supposed, depend on the presence of any 
morbid poison, but differs from the malignancy of the 
ulcerative stage of the common indurated testicle merely 
with regard to the part of the gland in which irritation 
causing its derangement has been primarily established. 
In illustrating this opinion, it is to be remarked that when 
a testicle is effected by true scirrhus, as it is termed, 
its morbid ulceration will be found to originate within its 
organic structure ; but when the gland becomes indura- 
ted and enlarged, in consequence of exterior causes of ex- 
citements, the morbid symptoms are, in the first in- 
stance, entirely confined to the surrounding or interve- 
ning cellular substance. And hence, alone, it is that 
scirrhous is attended at an early period with a peculiar 
sallowness of countenance, and other symptoms of de- 
rangement in the system ; while the common indurated 
testicle will exist, and frequently advance to a great ex- 
tent, without at all interfering with the general health of 
the patient." 

There can be no question as to the propriety of em- 
ploying bougies in order to dilate a stricture of the ure- 



20 ELEMENTS OF SURGERY. 

thra if it exist, but the extirpation of the testicle is not the 
less necessary because the incurable disease has been 
excited by "a latent principle of irritation in the 
urethra. " 

The testis is doubtless liable to very numerous dis- 
eases, some of which have never been sufficiently inves- 
tigated; one of these is an obstinate sinuous ulcer, which 
resists every caustic application, and refuses to heal even 
when all the diseased parts are, to all appearance, dis- 
sected or burnt out. Another is the fungous tumour 
which has lately excited some attention, and on which 
Mr. LaAvrence has recently published a paper which I 
have not been able to procure. This fungous tumour I 
have known cured in a variety of cases, by the applica- 
tion of white oxyd of arsenic (or arsenious acid) a reme- 
dy, therefore, which I take the liberty to recommend, 
previously to removing the parts by the knife, which has 
been the general practice. 

OPERATION. 

The extirpation of the testis, when necessary, is an ope- 
ration by no means difficult. The skin of the scrotum 
becomes contaminated sooner than any other part in the 
vicinity, and therefore the first thing, as Mr. Home re- 
marks, is to mark out that portion of skin which ought to 
be removed. " This being done, the next thing is to 
dissect out the diseased testicle from its situation in the 
scrotum, taking care that the incision should always be 
in the sound and natural parts and that every thing con- 
nected with the disease is left attached to the testicle it- 
self. Having gone thus far, the cord is to be examined, 
and dissected as high up as is necessary to come at a 
sound part, which, in the exposed state it is now in, de- 
tached from the skin and surrounding parts, can readily 



ELEMENTS OF SURGERY. 21 

be ascertained. All that is necessary to complete the 
operation is tying the cord, which is best done by pass- 
ing a needle, armed with a double ligature, through it, 
in the interstice between the portion composed of the vas 
deferens and spermatic artery, and the loose veins and 
other parts, which, in a diseased state of the testicle, 
are found much increased in size, and very vascular. 
These ligatures are to be tied sufficiently tight to deaden 
the substance which is included in them, and then the 
cord is to be divided. 

" The cut edges of the scrotum are to be brought to- 
gether, and retained there by needle and ligature, adhe- 
sive plaster, or, simply by compresses of lint, according 
to the peculiar circumstances of the case. 

" It is a common practice, which is adopted by sur- 
geons of eminence, to cut down upon the cord, in the first 
instance ; and, after exposing it for an inch in length, to 
pass a ligature behind it ; and, having thus included the 
cord, and secured the spermatic artery, divide it below 
the ligature, and afterwards dissect out the testicle, like 
any other detached tumour. The motives for this prac- 
tice are founded in humanity, since the moment the 
nerves of the testicle are cut through the patient- will be 
sensible of no material pain during the rest of the opera- 
tion. This advantage appears to me to be more than 
counterbalanced by the risk there is of the operation not 
being completed in the most satisfactory manner. 

" The first consideration in every operation in surgery 
is, that it should be so performed as to leave nothing to 
chance, and that the patient should have every security 
that the operation can afford him ; its being done with a 
less or greater degree of pain, however desirable it may 
be that it should be as small as possible, is therefore only 
a secondary consideration. 

" From not seeing operations in this extensive view. 



^ 



22 ELEMENTS OF SURGERY. 

young surgeons, upon slight grounds, are induced by 
theoretical opinions, to vary their mode of performing 
them, and too often make themselves liable to meet with 
more serious difficulties than those which they feared to 
encounter. 

" In this operation it is even recommended to cut down 
upon the cord, expose the spermatic artery, include it by 
itself in a ligature ; and, by this neat and delicate opera- 
tion, save the patient much pain. Those cases, however, 
which require an operation, have the cord much thick- 
ened, and consequently much more vascular than in its 
natural state. I have known a surgeon take up the sper- 
matic artery alone, then five or six vessels one by one ; 
and, after having kept the patient the time necessary for 
this purpose, find himself obliged to include the whole 
cord in a strong ligature, so many other vessels conti- 
nued to bleed." (Home.) 

I wish merely to add to Mr. Home's account of this 
operation, that the best mode of tying the cord, is in my 
opinion to pass one strong ligature round the whole of 
it, including every nerve and vessel in it. The pain is 
not augmented, nor its duration increased by this, and 
the operation is greatly expedited by it. In making the 
first incision I would also recommend to carry the edge 
of the knife into the substance of the testis, which will 
immediately demonstrate the nature of the tumour, and 
will certainly divide all the investing membranes, which 
it is useless to do by a slow, cautious, and painful dis- 
section. 



ELEMENTS OF SURGERY. 23 

CHAPTER II. 

Of Fungus Hematodes. 

Within a few years much attention has been paid 
to a disease which has received the appellation of fun- 
gus hematodes, a soft cancer. Mr. Burns of Glasgow, 
is the first writer who has given an exact account of it. 
He states that " it generally begins with a small colour- 
less tumour which is soft and elastic, if there be no 
thick covering over it, such as a fascia ; but otherwise 
is tense. At first, it is free from uneasiness ; but, by 
degrees, a sharp acute pain darts occasionally through 
it, more and more frequently, and at length becomes in- 
cessant. For a considerable time, the tumour is smooth* 
and even ; but, afterwards, it projects irregularly in one, 
or more points ; and the skin at this place becomes of a 
livid red colour, and feels thinner. In this place it ea- 
sily yields to pressure, but instantly bounds up again. 
Small openings now form in these projections, through 
which is discharged a thin bloody matter. Almost im- 
mediately after these tumours burst, a small fungus pro- 
trudes, like a papilla, and this rapidly increases, both in 
breadth and height, and has exactly the appearance of a 
carcinomatous fungus and frequently bleeds profusely. 
The matter is thin, and exceedingly fetid, and the pain 
becomes of the smarting kind. The integuments, for a 
little around the ulcers, are red, and tender : after ulce- 
ration takes place, the neighbouring glands swell, and 
assume exactly the spongy qualities of the primary tu- 
mour. If the patient still survive the disease in its pre- 
sent advanced progress, similar tumours form in other 
parts of the body, and the patient dies hectic. 



24 ELEMENTS OF SURGERY. 

"After' death, or amputation, the tumour is found to 
consist of a soft substance, somewhat like the brain, of 
a grayish colour, and greasy appearance, with thin mem- 
brane-like divisions running through it, and cells or ab- 
scesses in different places, containing a thin bloody mat- 
ter, occasionally in very considerable quantity. There 
does not seem uniformly to be any entire cyst, surround- 
ing the tumour ; for it very frequently dives down be- 
twixt the muscles, or down to the bone, to which it often 
appears to adhere. The neighbouring muscles are of a 
pale colour and loose their fibrous appearance, becoming 
more like liver, than muscle. The bones are always ca- 
rious in the vicinity of these tumours. 

" The distemper is sometimes caused by external 
violence, though in general there is no evident cause 
whatever." I fully agree with Mr. Wardrop in con- 
sidering this affection distinct from cancer, although in 
'some respects they are very similar. They differ in 
structure very materially ; in the symptoms which arise ; 
in the parts usually attacked, and in the periods of life 
at which they occur. (See Wardrop on fungus nema- 
todes, or soft cancer.) 

The fungus hematodes occurs in different parts of the 
body. I have seen one case in which it sprouted from 
under the tendon of the biceps flexor cruris, and in 
another its situation was so high in the arm, that ampu- 
tation was performed very near the should er joint, and 
a third case in which I have been obliged to amputate 
at the shoulder. 

Mr. Hey has seen it in the female breast ; in the leg, 
neck and arm; on the back of the shoulder, and he 
thinks, also in the eye. Mr. Burns has seen it in the 
hip joint ; upon dissection he found the joint surrounded 
with a soft matter resembling the brain enclosed in thin 
cells, and here and there, cells full of thin bloody water ; 



ELEMENTS OP SURGERY. 25 

Ihe head of the thigh bone and the acetabulum were ca- 
rious. Mr. Wardrop describes cases in which it occur- 
red in the eye, the testicle, the liver, the spleen, kid- 
neys, lungs, uterus and ovaria. 

With respect to the treatment of fungus nematodes, it 
must be confessed that there is no remedy but an entire 
extirpation of all the affected parts, and unfortunately, 
the patient often opposes this decisive practice in the 
commencement of the disease, which is the most proper 
time for it. Mr. Hey has applied numerous escharotics 
without the effect of checking the growth of the tumour. 
When the disease is seated on a limb, it ought, ii possi- 
ble, to be removed without amputation. Not a vestige 
of morbid structure should be left after the operation, 
but the incisions should be made in sound parts, and if 
notwithstanding this, the disease should be reproduced, 
amputation ought to be performed without delay. Wher- 
ever the disease is seated, the parts ought to be freely 
and carefully removed. 



Vol. II. fc 



J6 ELEMENTS OF SURC4ERY. 

CHAPTER III 

Of Hernia. 

The large proportion of mankind who are afflicted 
with this complaint; — the great variety of forms in 
which it appears ; — the fatality which results from its 
improper treatment, and the ample resources of surgery 
in preventing its evil consequences, are circumstances 
which combine to render the investigation of hernia pe- 
culiarly interesting. 

It has been estimated that nearly one fifteenth part of 
the inhabitants of Great Britain, of Spain, and of Italy, 
are affected with hernia, and one thirtieth of the popula- 
tion in the north of Europe. The proportion in America, 
I am persuaded, is by no means so great ; but it is never^ 
theless a very frequent disease, occurring in both sexes, 
at every age^. and in every rank of society* 

A hernia, or rupture, signifies a protrusion of any 
of the contents of the abdomen, through the parietes of 
that cavity.* The parts at which this protrusion occurs^ 
and the particular viscera which are thus displaced, are 
various. 

The peritoneum which lines the cavity of the abdomen 
is generally pushed out together with the viscera, form- 
ing a bag called the hernial sac, which is a cavity con- 
tinued from that of the abdomen and lined by the same 
membrane. 

* Dr. Monro in order to include every species of hernia in a definition, calk 
it " a tumour unconnected with a wound, and produced by a bowel, or part of 
a bowel, which is not situated in its natural place, and the tumour may be either 
external or internal." It is useless to be fastidious respecting definitions ; they 
are very seldom perfect. 



Platf. jri-j 



//, 



'/'///// 




(rami / rn/s 




■1/ J 'riii.~ 



ELEMENTS OF SURGERY. 27 

In general the bowels are protruded at some natural 
opening, as the abdominal ring, or crural arch ; by the 
term opening, in this place, is not meant any absolute 
hole or aperture, because in a natural state these parts 
are filled up with cellular texture, but this texture being 
less dense and resisting than the neighbouring parts, 
yields more readily. Sometimes the hernia occurs at a 
prceter natural opening, in some part of the abdomen. 

The hernial sac, after passing out at the aperture 
through which it has been forced, gradually enlarges, in 
consequence of the action of the muscles of the abdomen, 
which augments its contents, and of other causes. The 
cellular membrane in the vicinity gives but little resist- 
ance to this enlargement ; the part of the sac, however, 
which is surrounded by the firm parietes of the abdomen, 
is prevented from yielding, and remains of a smaller 
diameter than the rest of the sac, forming what is called 
its neck ; — the extremity most distant from the neck is 
called the fundus of the sac. 

This sac varies greatly in density, not so much from 
an alteration in the thickness of the peritoneum itself, as 
from the layers of condensed cellular texture which are 
connected with it. In very old ruptures the hernial sac is 
sometimes very dense, it has been known half an inch in 
thickness ; but, in other cases, a contrary state of the 
sac is found, and it appears to be almost entirely de- 
stroyed. In old umbilical hernia' it is often extremely 
thin, and cases are recorded in which no sac could be 
found ; in these cases it had probably been absorbed, in 
consequence of pressure, which we know sometimes oc- 
casions an absorption, and sometimes a thickening of the 
compressed parts.* 

• The sternum is absorbed from the pressure of an aneurism of the aorta, 
and the soles of the feet are covered with a very thick skin, in consequence of 
compression from the weight of the body 



28 ELEMENTS OF SURGERY. 

« We should hardly have supposed, a priori, that the 
peritoneum is susceptible of such considerable extension 
as it frequently suffers in cases of hernia. Scrotal rup- 
tures often descend to various distances on the thigh, 
sometimes indeed even to the knee ; yet the whole inner 
surface of the bag, in which all the loose viscera of the 
abdomen may be contained, is lined by a continuation of 
peritoneum ; indeed, the hernial sac is generally thicker 
and stronger in proportion to the size of the tumour, and 
to the duration of the complaint. Yet, occasionally, in- 
stead of an increased thickness, we observe the opposite 
process of absorption or thinning, in large ruptures : 
in some cases the coverings are so reduced, that the con- 
volutions and vermicular motions of the intestines may 
be distinguished through the skin ; hence it may appear, 
that the sac is entirely wanting ; but it will be possible 
to trace it in the neighbourhood of the opening. The 
contents of a rupture may be found immediately under 
the skin, when the hernial sac has been burst by a blow ; 
but this is an unfrequent occurrence. 

" The exterior covering is every where closely con- 
nected by cellular substance to the proper peritoneal sac. 
Hence the latter part is not returned into the abdomen, 
when the contents of the swelling are replaced ; but re- 
mains behind, ready to receive any future protrusion. 
At the first moment of the occurrence of a hernia, the 
protruded peritoneum must of course be unconnected to 
the parts among which it lies. But adhesions take place 
so quickly that we find the sac universally connected to 
the contiguous parts, even in a rupture of a few days 
standing : and these connections become afterwards so 
strong and general, that we might suppose the hernial 
sac to have been originally formed in its unnatural situa- 
tion. The difficulty, which this structure would occa- 
sion, in, separating the hernial sac from the surrounding; 



ELEMENTS OF SURGERY. 29 

parts, and particularly from the spermatic cord, con- 
stitutes an insuperable objection to any proposal for re- 
turning the sac into the abdomen, and must have been a 
source of great danger in some of the old methods of at- 
tempting the radical cure of ruptures." (Lawrence.) 

All abdominal hernise are to be considered as having 
sacs, except those which are consequent to wounds 
or preternatural openings in the parietes of the abdo- 
men, and those in which the sac has been absorbed. 
Hernia of the bladder has no sac, because its situation is 
exterior to the peritoneum. 

" The contents of a hernial sac are some part or parts 
ordinarily contained in the abdomen ; and commonly the 
omentum or intestine*. These are the most moveable 
viscera, and occupy the front and lower part of the belly : 
their relative position explains, why, in a mixed case, 
the latter are covered by the former. The small intes- 
tine, from the greater looseness of its connexion, is more 
frequently protruded than the large; and the ileum more 
frequently than the jejunum, in consequence of its great- 
er proximity to the ring and crural arch. A part only 
of the diameter of the tube is sometimes included in 
a hernia; any larger quantity may descend from a sin- 
gle fold to the whole moveable portion of the canal. 
Adipous matter is generally deposited in large quanti- 
ties in the omentum of fat and elderly persons ; and in 
this state it escapes very readily from the cavity. Pro- 
trusion of the large intestines consists, generally, either, 
of the co'cum, or sigmoid flexure of the colon ; as these 
arc the least fixed portions of the canal. When the for- 
mer part descends, it is ordinarily, as we should expect, 
on the right side ; when the latter, on the left. Yet the 
ccecum and vermiform appendix have been seen in rup- 
tures of the left side; and when we consider that the in- 
testines may descend to the knees, dragging even the sto- 



30 ELEMENTS OF SURGERY. 

mach to the pubes, we shall be convinced that the natural 
position of an organ cannot of itself, enable us to de- 
termine at which opening it may be protruded. 

" Other abdominal viscera, besides the intestines and 
omentum, may be protruded in hernia. The urinary 
bladder sometimes passes through the abdominal ring. 
The ovaries, and uterus, the spleen and stomach, have 
been very rarely seen in ruptures." (Lawrence.) 

Hernise derive different appellations from the part at 
which the intestines protrude, from the situation in which 
they make their external appearance, and from the parts 
contained within the hernial sac. Inguinal hernia 
denotes a protrusion at the abdominal ring, forming a 
tumour in the groin, this hernia is also called bubono- 
cele. In the male the tumour extending down into the 
scrotum is called oscheocele or scrotal hernia. In 
femoral or crural hernia (sometimes called mero- 
cele) the protrusion takes place under the crural arch. 

EXOMPHALOS, OMPHALOCELE, Ol* UMBILICAL HERNIA, is 

that rupture which takes place at the navel. In any 
other part of the abdominal parietes, hernia are called 

VENTRAL. 

Hernia congenita is that in which the tunica vasi- 
nalis testis, forms the hernial sac, the testis and intestine 
being in contact 

In addition to these more common cases of hernise, 
there are some rare species which deserve to be mention- 
ed, as hernia of the perineum, where the parts are 
protruded by the side of the bladder or vagina, or, a 
tumour may be formed in any part of the vagina, forming 
vaginal hernia. The ischiatic rupture, and that of the 
foramen ovale, take place through these respective open- 
ings oi' the pelvis. 

When the sac contains omentum, the case is called 
epiplocele, or omental hernia; when intestine, enterq. 



ELEMENTS OF SURGERY. 31 

cele or intestinal hernia; when both these parts are 
contained in the sac,it constitutes entero-epiplocele. 
A protrusion of the urinary bladder forms cystocele, or 
hernia vesci». 

Hernia are reducible when the parts can be passed 
up into the abdomen. When from having contracted adhe- 
sion, or being greatly enlarged, they cannot be returned, 
they are said to be irreducible. When they are irre- 
ducible in consequence of a stricture formed at the ori- 
fice through which the viscera protruded, the hernia is 
said to be strangulated, or incarcerated. 

The causes of hernia, are, 'predisposing debility of any 
particular part of the parietes of the abdomen, whether 
natural, or the consequence of morbid affections — and 
violent efforts by which the muscles of the abdomen 
are made to contract forcibly upon their contents — lifting 
heavy weights, — jumping, — running, — violent coughing, 
parturition — vomiting — straining at stool, and many 
oilier analogous exertions of the muscles; these are the 
occasional causes of hernia. 



32 ELEMENTS 



CHAPTER IV. 

Symptoms of Reducible Hernia. 

A tumour is observed at the place of protrusion, free- 
from pain, and generally soft, the colour of the skin be- 
ing unaltered. This swelling varies in size, being small- 
er in a recumbent, than in an erect posture, and the 
patient is generally able by lying down to return the 
parts into the belly, the tumour entirely subsiding. The 
swelling increases when the patient is flatulent ; some- 
times a rumbling sensation is perceived in it, occasioned 
by wind. Coughing, sneezing, or any effort of the ab- 
dominal muscle produces an increase and tension of the 
swelling. These symptoms are more or less evident in 
different cases, they are not all observable in every in- 
stance. 

" The symptoms of the case will sometimes inform us 
what are the contained parts. This discrimination, in- 
deed, is often difficult, and even impossible, when the 
hernia is old, large, and very tense. For the viscera in 
such ruptures experience considerable changes in their 
figure and state, while the thickened hernial sac prevents 
an accurate examination by the hand. Again it is fre- 
quently hard to determine the contents of a very small 
hernia. 

u If the surface of the tumour be uniform ; if it be 
elastic to the touch ; if it become tense and enlarged 
when the patient is troubled with wind, holds his breath, 
or coughs ; if in the latter case, the tumour feel as if it 
were inflated ; if the part return with a peculiar noise, 
and pass through the opening at once, the contents of the 
swelling are intestine. If the tumour be compressi- 



ELEMENTS OF SURGERY. 33 

ble ; if it feel flabby and uneven on the surface ; if it be 
free from tension, under the circumstances just enume- 
rated ; if it return without any noise, and pass up very 
gradually, the case may be considered an epiptocele. 

" The smooth and slippery surface of the intestine 
makes its reduction easier ; and the mixture of air with 
the intestinal contents, causes, when they are pressed 
up, a peculiar guggling noise, (Gargouillement of the 
French.) The reduction of the omentum is more diffi- 
cult, since it is soft and uneven, and its surface becomes 
moulded by the surrounding parts. If a portion of the 
contents slip up quickly, and with noise, leaving behind 
something which is less easily reduced, the case is pro- 
bably an entero-cpiplocele." (Lawrence.) 

This, however, is only probable evidence, and should 
not be depended on with too much confidence. The 
symptoms enumerated are, however, amply sufficient to 
enable us to discriminate between hernia and all other 
diseases, except in very particular cases where the tu- 
mour is small and deeply seated, has arisen very gra- 
dually, is connected with other tumours, and contains 
much fluid, &c. In a fat patient the difficulty of discri- 
mination is considerably augmented. 

" A reducible hernia, though attended with no imme- 
diate danger, occasions much trouble to the patient, par- 
ticularly if it be allowed to proceed unrestrained by sur- 
gical treatment : and the inconvenience increases con- 
stantly with the size of the tumour. The portion of in- 
testine or omentum, which has left the abdomen, pro- 
duces various complaints, from its connexion with the 
parts within. From this source of irritation proceed 
nausea and vomiting, indigestion and colic. As the vis- 
cera become accustomed to their unnatural situation, 
Vol. II. F 



34 ELEMENTS OF SURGERY. 

these symptoms gradually wear away. Still, as the tii 
mour constantly increases in size, a large part of the vis- 
cera is deprived of that pressure and support, which it 
naturally derives from the respiratory muscles; the pas- 
sage of the food through the alimentary canal becomes 
difficult and protracted; and hence large ruptures are 
almost invariably attended with flatulency and constipa- 
tion. The patient is precluded from all active and la- 
borious employments, and from all considerable exer- 
tions, which necessarily augment the tumour, and are 
attended with great risk of more immediate danger, by- 
forcing down fresh parts, so as to cause strangulation. 
The opening through which the viscera pass out, must 
subject them to more or less pressure ; which will enable 
us to account for that effusion of fluid into the cavity of 
the sac, which is generally observed in old ruptures ; 
and for the formation of those adhesions of the parts to 
each other, and to the hernial sac, which change the case 
from a reducible swelling to one which will no longer 
admit of reduction. Since the opening becomes enlarged 
by the protruded parts, and the pressure on the viscera, 
which causes the descent, is frequently renewed, addi- 
tions to the tumour take place very readily. In situa- 
tions where position is favourable, and the surrounding 
parts offer no obstacle, as in the scrotum, the only limit 
to the possible bulk of a rupture arises from the con- 
nexions of the parts within. Instances are not uncom- 
mon, where all the moveable viscera have been contain- 
ed in such a swelling ; and even those which are more 
fixed may be gradually displaced, by the constant drag- 
ging of organs connected with them." (Lawrence.) 



ri.A'J'EXlTJl. 



Neck, of 1/14 Sa 



gtrart) 



,/.<'"'•'" 



Cavity ofth& Sac 



j;„M«<»../ ring 




"^^^. 



Incision, into th* Sac 
in, the Scrotum 



J. SjDewq? dd/. ic So. 



ELEMENTS OF SURGERY. 35 

CHAPTER V. 

Symptoms of Strangulated Hernia. 

" The first and most immediate effects of such a de- 
gree of pressure, as prevents the return of the protruded 
parts, are an obstruction to the passage of the intestinal 
contents, and consequent want of fecal evacuations ; and 
a more or less violent inflammation in the strangulated 
part. The former symptom may not be so clearly marked 
where a part only of the diameter of the gut is strangu- 
lated, but it will often occur to as great a degree in that 
<:ase, and will be equally insuperable by purgative medi- 
cines, as where a complete fold of intestine is included : 
it even happens occasionally in a mere epiplocele, where 
no intestine at all is protruded. Hence it must be re- 
ferred rather to that inflammatory affection of the intes- 
tines, which subsists in this complaint, than to the 
mechanical obstruction of the canal : and must be con- 
sidered as analogous to the constipation which prevails 
in ileus, when produced by other causes. The action of 
clysters on the bowels below the stricture often produces 
a stool after the strangulation has taken place. But when 
these have been once emptied, the most irritating clys- 
ters produce no effect. The inflammation of the pro- 
truded viscera causes a thickening of their coats, an 
effusion of fluid into the hernial sac, and adhesions of 
the parts to each other, and to the containing bag. 
When it is particularly violent a layer of coagulating 
lymph is sometimes thrown out on the surface of the in- 
testine. A manifest impression is often made on the 
intestine by the stricture, and this may proceed so far 



36 ELEMENT S OF STJ R C5 ERY. 

as to cause a considerable constriction of tlie canal. It 
terminates at last, unless the stricture be previously re- 
moved, in gangrene. These, which Ave may call the 
primary effects of the incarceration, are accompanied by 
other symptoms, arising from disorder of the parts 
which sympathize with the hernia. 

"In an incarcerated intestinal rupture, the tumour 
which was before indolent, becomes painful ; the pain 
is most acute at the strictured portion, and extends from 
that situation over the rest of the swelling and abdomen : 
these parts becoming at the same time swollen and tense. 
A feeling of tightness, as if from a chord drawn across 
the upper part of the belly, is often one of the earliest 
symptoms of strangulation. The pain, which at first is 
not constant, becomes in the sequel fixed ; and is aug- 
mented by external pressure, coughing, sneezing, or other 
agitations of the body. The evacuations per anum are 
entirely suppressed, and nausea and vomiting ensue : 
all the contents of the stomach, and afterwards those of 
the intestine, down to the stricture, being rejected. 
These symptoms, which often remit for a considerable 
period, are accompanied with a proportionate derange- 
ment of the whole system. There is a great anxiety and 
restlessness, with a small, quick and hard pulse, and 
coldness of the extremities. The pulse cannot be at all 
depended on, as indicating the degree of general fever. 
It may be even slower than in health, when the patient 
is in the greatest danger. Neither does the degree of 
heat, as ascertained by our examination, or indicated by 
the patients sensations, correspond to fevers in general : 
on the contrary there is a disposition to cold sweats, and 
a cold state of the extremities. After a time hiccough su- 
pervenes, the pulse becomes so small as hardly to be 
sensible, the respiration is weak, and the whole body is 
covered by a cold and clammy sweat. Mortification now 



ELEMENTS OF SURGERY. 

s place ; it begins in the contents of the rupture, and 
::ds to the containing and neighbouring parts. The 
degree and intensity of the symptoms are modified by 
various circumstances, as the age and strength of the pa- 
tient, the nature of the strangulation, &c. The duration 
of the complaint, from its first commencement to the ter- 
mination in mortification or death, is also extremely 
various. 

A.n epiplocele is much less liable to strangulation 
than an intestinal rupture, and its symptoms are milder 
and slower in their progress. In this variety of the com- 
plaint, stools may generally be procured by purgative 
medicines or clysters. The connexion of the omentum 
with the stomach induces hiqeough and sickness, and 
although the latter symptom seldom proceeds to stercora- 
ceous vomiting, it exists to a most distressing degree, 
and particularly characterizes the complaint. The 
symptoms are often influenced by the position of the body, 
being mitigated by bending, and aggravated by straight- 
ening the trunk- An epiplocele is occasionally accom- 
panied with all the dangerous and alarming symptoms 
of an intestinal rupture, as insuperable constipation, 
fecal vomiting, $ 

" The examination of a patient, who dies while la- 
bouring under a strangulated hernia, discloses such a 
stale of parts as the symptoms just enumerated would 
naturally lead us to expect. The whole surface of the 
peritoneum is inflamed, and the intestines participate in 
this disorder, particularly that portion of the canal which 
is above the stricture, which is distended considerably 
beyond its natural diameter. From the constricted part 
downwards, the intestine is generally smaller than usual, 
and not inflamed. The convolutions of the intestinal 
canal are agglutinated by a recent deposition of coagu- 
lating lymph ; and a turbid puriform fluid, with coagu- 



38 ELEMENTS OF SURGERY. 

lated flakes, is effused into the abdomen ; streaks of a 
bright and red colour, consisting of an aggregation of 
minute vess is, cross the intestines in different directions ; 
and spots of gangrene are not unfrequently observed. 
All these circumstances show us most decidedly that the 
effects caused by strangulation are of the most active in- 
flammatory kind. We must regard the stricture, which 
the protruded parts experience, as the immediate cause 
of this disorder. 

"The distinction of strangulation, from affections 
which may resemble it more or less nearly, requires con- 
siderable attention and judgment. The intestine in- 
cluded in a large hernia may be affected with colic, and 
thus giving rise to constipation and vomiting. This 
may the more easily be mistaken for strangulation, if 
the parts are adherent, and incapable of reduction. Such 
an attack may render a reducible hernia incapable of 
being replaced; particularly if the bowels are much in- 
flated. Clysters and oily purgatives will produce stools 
under these circumstances, and thereby throw light on 
the real nature of the case. 

" The first appearance of a rupture may occasion hic- 
cough, vomiting, and the same symptoms may be exhi- 
bited in an old case, after the patient has taken much 
exercise, or remained long in the erect posture, in conse- 
quence of irritation, excited by the protruded viscera in 
the contents of the abdomen. Here too stools may be 
easily procured by purgatives." 

" The most important case, however, is where a pa- 
tient with a rupture has an attack of ileus from some 
other cause, in which the original complaint is not at 
all concerned. The operation, performed on the suppo- 
sition that the symptoms arise from the hernia, would 
here be not only useless, but even injurious ; and the 



ELEMENTS OF SURGERY. 39 

surgeon would neglect those means, which the inflam- 
mation of the bowels so urgently demands. 

" Whenever we see a patient labouring under the 
symptoms of ileus, we should suspect the existence of a 
rupture, and make those inquiries and examinations, 
which such a suspicion would naturally suggest, par- 
ticularly in females, who are t often led to concealment 
by motives of false delicacy. A superficial examination 
is not sufficient on these occasions ; as a very small por- 
tion of intestine, not forming an external tumour, may, 
by its incarceration, cause the symptoms. If the latter 
have appeared suddenly, and under circumstances which 
might cause a rupture ; if the pain have been first felt 
about the ring or crural arch, and if pressure in these 
situations increase it ; and, lastly, if the patient, shortly 
before, had been in perfect health, there is strong reason 
to suspect the existence of a hernia. 

u When a person labouring under ileus has a hernia, 
which can be reduced easily, there is no ground for 
doubt ; if, on the contrary, the parts cannot be replaced, 
strangulation may be reasonably suspected, although we 
cannot immediately conclude, with certainty, that the 
swelling is the cause of the inflammation. We should 
first ascertain whether the parts could be replaced pre- 
viously to the attack ; if they could not, and the swelling 
be hard and old, they are probably adherent, and the 
impossibility of reduction proves nothing. If they could 
be returned, and particularly a short time only before 
the access of the symptoms, strangulation may be sus- 
pected with justice; but it is still not quite certain." 
(Lawrence.) 

Strangulation consists in pressure upon the protruded 
parts. As this pressure is generally made by a tendon, 
it is perhaps improper to use the term stricture, and 
Mr. Lawrence objects to employing it, asserting that the 



10 ELEMENTS OF SURGERY. 

aperture is generally dilated instead of being contracted. 
I would beg leave to remark here, however, that the re- 
lative size of the ring, or part which makes the compres- 
sion, and of the compressed parts, is so changed when 
strangulation takes place that the term stricture may be 
retained, provided the passive nature of the tendinous 
aperture be kept in view. A portion of omentum or in- 
testine pushed forcibly through the abdominal ring may 
become strangulated, or the contents of an old hernial 
sac may be suddenly increased by the descent of more 
intestine, or by faeces or flatus, in such a manner as to 
become strangulated. 

The neck of the sac as well as the aperture in the 
parietes of the abdomen is capable of making constriction 
upon its contents, in consequence of the thickening and 
induration which the peritoneum undergoes in some 
cases of hernia. 

Mr. Astly Cooper believes that in some cases of in- 
guinal hernia the stricture is truly spasmodic ; he says 
that " when the strangulation is above the ring, a por- 
tion of intestine protrudes under the edge of the internal, 
oblique, and transversalis muscles, compressing them, 
which ill their turn being excited to contraction by the 
irritation of this pressure, react upon the intestine with 
a force sufficient to produce a strangulation accompanied 
by spasmodic symptoms." 

The strangulation in some instances comes on imme- 
diately. I have known a patient straining at stool sud- 
denly force down an additional portion of intestine into 
an old hernial sac ; and immediate strangulation was the 
consequence. In such cases " the symptoms, Mr. Law- 
rence remarks, come on suddenly, and their progress is 
rapid ; the swelling is tense and highly painful, particu* 
larly at the ring, Avhere the slightest pressure is intole- 
rable : the abdomen quickly becomes painful, and is 



ELEMENTS OF SURGERY. 41 

tense and elastic to the feel. The constitutional affec- 
tion partakes of the inflammatory character. So quickly 
does the complaint run through its stages in this case 
that grangrene has been known to occur in twenty-four 
hours from the expulsion of the intestine." 

In other cases the strangulation is slow r and progres- 
sive. In some of these cases many days elapse before 
it is complete. In such cases successful operations have 
been performed a fortnight, and even three weeks after 
the commencement of incarceration. This slow stran- 
gulation generally happens in large old hernia? which 
have been often protruded and replaced, or which have 
been long unreduced. There is generally an unusual 
heaviness and hardness of the tumour in such cases ow* 
iug to an increased quantity of the contents of the intes- 
tine. 

Inflammation sometimes attacks the parts protruded 
from the abdomen, especially in cases where the tumour 
is very large. This if possible should be distinguished 
from strangulation, and although it be difficult to discri- 
minate, yet it may sometimes be done by careful atten- 
tion. The ring will be found in the present case free 
from tension, and the parts within it, will not appear 
compressed. If the ring, however, should become tense, 
and the protruded bowels painful, the case ought to be 
treated as if strangulated. 



Vol. II. 



42 ELEMENTS OF SURGERY* 

CHAPTER VI. 

Treatment of Reducible Hernia. 

« The treatment of a reducible rupture comprehends 
the return of the protruded parts, and their retention 
within the abdominal cavity by means of an appropriate 
truss. The necessary observations concerning the mode 
of replacing ruptures will be delivered, when the treat- 
ment of strangulated hernia is considered. 

" So long as the protruded viscera can be made to 
pass freely into the abdomen, this complaint carries with 
it no immediate danger to the patient. It may indeed be 
troublesome, both from the bulk of the swelling, and 
from the intestinal derangements, which the residence 
of the viscera in their unnatural situation is apt to create ; 
but, independently of these circumstances, it may exist 
throughout life, without causing more than slight incon- 
venience. This innocent state of the disorder, cannot, 
however, be at all depended on ; as numerous accidental 
causes may at any time bring it into a condition, where 
the life of the patient is exposed to the greatest risk. A 
trifling bodily exertion, by forcing down an additional 
quantity of the bowels, an excess in eating or drinking, 
an indigestion, or any intestinal disorder, may convert 
the rupture from a reducible to an incarcerated state. 
Should the patient escape this fate, the unrestrained in- 
crease of the swelling constitutes a sure source of future 
inconvenience and disease. The vast size to which ne- 
glected hernia sometimes increases, not only prohibits all 
active exertion ; but, by involving in the male, the inte- 
guments of the penis, incapacitates the subject from the 



ELEMENTS OF SURGERY. 43 

act of copulation, and gives rise to excoriation from the 
discharge of the urine over the swelling. Probably too 
the testis may be affected by the pressure of a very large 
scrotal hernia. Disorders of the intestinal functions in- 
variably attend these large ruptures, aiul increase in fre- 
quency and violence, in proportion to the size of the 
swelling, and age of the patient. All the moveable vis- 
cera of the abdomen gradually find their way into the 
hernial sac, if a rupture be entirely neglected. Nume- 
rous instances are recorded, in which the jejunum, 
ileum, colon, and omentum, have been entirely included. 
The constant force acts even upon the more fixed parts, 
and entirely changes their relative positions ; thus the 
stomach is brought into a perpendicular line parallel to 
the axis of the body ; and its pyloric orifice has been ac- 
tually within the mouth of the sac. It was drawn down 
to the pubes in the case of Mr. Gibbon. 

" These considerations should render every person af- 
flicted with a rupture, anxious to get the parts replaced, 
and to have a proper truss applied ; and they should lead 
surgeons to inculcate the necessity of these measures, as 
forcibly as they can on the minds of all such as seek re- 
lief from their advice." (Lawrence.) 

OF TRUSSES. 

The object in applying a truss, is to close the opening 
by which the viscera protrude, by permanent pressure, 
and thus when the parts are reduced to prevent their re- 
descending. The best instrument for this purpose is an 
elastic spring of steel, so constructed as to make pres- 
sure upon the precise spot where the protrusion takes 
place. When this spot is the abdominal ring, or the 
< rural arch, the truss in common use, provided it fit the 
patient accurately, is the best instrument hitherto em- 
ployed. 



44 ELEMENTS OF SURGERY. 

It consists of a flat narrow piece of steel passing- 
round the body, and adapted to its form ; it terminates 
in a plate of iron which is to be fixed over the place 
of protrusion. The posterior surface of the plate is 
furnished with a convex cushion termed the pad, 
adapted in form and size to the opening which it is de- 
signed to close. The spring is covered externally with 
leather that may sit easily on the body. Its inner sur- 
face is lined with some soft substance. A strong strap 
extending from its posterior end passes round the sound 
side of the trunk, and is fastened to a hook on the front 
of the plate. This strap being perforated by several 
holes enables the patient to tighten or loosen the truss at 
pleasure. 

The curvature of the spring should be accommodated 
to the bread! h of the haunch in each individual, fortius 
varies very considerably. '& A piece of cork is fastened 
to the posterior surface of the iron plate, and this is co~ 
vered with leather stuffed with hair or wool, so as to 
give it the due firmness, and to bring it to a slight and 
uniform convexity." The size of the pad should be 
rather larger than the opening it is intended to cover. 

When the patient is ruptured in both groins he should 
have a double truss, one spring going quite round the 
body, and terminating in two pads, one over each aper- 
ture. 

Should the truss slip upwards, a strap may be passed 
between the thighs which will prevent it ; if downward 
it can he remedied by a shoulder strap ; but this is sel 
dom necessary except in very corpulent persons, and in 
if the instrument be properly constructed it 
mam proper position, 

" The pad of the truss should be placed over the 
opening at which the viscera have protruded : hence, in 
a small, or recently formed inguinal rupture, the proper 



ELEMENTS OF SURGERY. 45 

portion for it is considerably exterior to the pubes, and 
i -ather above that bone. The surgeon must, in all cases, 
endeavour to ascertain the precise point at which the 
rupture has taken place, and that is the right position 
for the pad. When he is going to apply the truss, he 
will place it round the pelvis, and put the patient into 
the recumbent position. Having carefully replaced the 
whole protrusion, he presses on the opening with one 
hand, and with the other applies the pad of the truss in 
its proper situation, holding it there until he has adjust- 
ed the rest of the instrument, and fastened the strap to 
the plate. The patient will follow the same plan in ap- 
plying the instrument himself; and the most convenient 
time for this purpose is before he rises, as the viscera 
generally re-enter the abdomen during night, and have 
no disposition to descend again until he assumes the 
erect position. 

"When the bandage is applied, the patient rises, and 
the surgeon examines it carefully in every point, to see 
whether the skin is folded, pinched, or too much com- 
pressed in any situation. He may walk, cough, and 
make slight efforts for the purpose of ascertaining wheth- 
er the parts are well kept up ; and if they are not, it 
must arise from some error in the construction or appli- 
cation of the bandage which w ill require attention. 

(i If the viscera are well supported by the instrument, 
the patient may follow his ordinary occupations : yet he 
should bear in mind the affected part. Violent exercise 
or bodily exertion, and excess of eating or drinking 
should be avoided. The surgeon should examine him 
in two or three days. If any part has escaped, or if 
there be swelling or pain in the spermatic cord, some 
imperfection must exist in the instrument, and must be 
remedied. The omentum very often escapes, and great 
difficulty is frequently experienced in keeping it reduced. 
Tt may be necessary, if the pad retains its situation on 



46 ELEMENTS OF SURGERY. 

the ring, and the truss in general sits well, to tighten 
the strap a little. Some individuals find the pressure of 
the truss extremely disagreeable at first, although it is no 
more than the case requires. These may wear a very 
weak instrument for an hour or two daily, increasing the 
length of time of such application, until habit has ren- 
dered its constant use supportable. 

» The use of an elastic truss not only keeps the vis- 
cera within the abdominal cavity, and thereby protects 
the ruptured person from all the dangers to which the 
existence of his complaint would otherwise expose him ; 
but if continued for a sufficient length of time, even af- 
fords a prospect of a radical cure. The constant pres- 
sure of the pad keeps the neck of the sac empty, and 
this part together with the surrounding tendinous open- 
ing, contracts, in obedience to the general law, by which 
all hollow parts of the body adapt themselves to their 
contents. Sometimes the truss excites a kind of slow 
inflammation, which produces an actual agglutination of 
the sides of the aperture." (Lawrence.) 

The patient often asks how long he must wear his 
truss: it is not easy to determine this. In young persons, 
it should be worn at least two years, and in elderly pa- 
tients during life. 

Mr. Lawrence dissected a patient in whom a very old 
and extensive rupture had in this manner been radically 
cured by an adhesion at the neck of the sac. In chil- 
dren there is great reason to expect radical cures in this 
manner, as many such have been effected. 

The truss should be worn constantly and not taken off* 
at night, as is the custom with many patients. When 
the cure is effected it may be laid aside, but this is a 
point not easily ascertained. When a person afflicted 
with hernia is obliged to make any unusual effort, he 
should forcibly press on the pad of the truss to prevent 
the ill effects of his exertion. 



ELEMENTS OF SURGERY. 47 

The degree of pressure necessary, varies in different 
cases, and is easily regulated by the thickness of the 
spring. In those cases which require so strong a spring 
as to produce pain by pressing on the spermatic cord, a 
hollow space should be left in the pad for that part ; this 
caution is particularly necessary when the testis or cord 
is in a diseased state. 

Mr. Grooch recommends in cases where the spermatic 
cord is enlarged, to have the pad constructed with a pro- 
jection in the middle, just sufficient to fill up the abdo- 
minal ring. 

A truss for umbilical hernia has been constructed by 
Mr. Marison of Leeds. It is composed of two pieces of 
thin elastic steel, which nearly meet behind the back ; 
in front they form an oval ring where they are thicker 
than at any other part. A steel spring and a pad of 
stuffed leather, are fastened to this ring, in such man- 
ner as to press upon the hernia. It is covered with soft 
leather and is tied with tapes behind. 

In the opposite plate are represented the trusses for 
inguinal, crural, and umbilical herniae. 



48 ELEMENTS OF SURGERY 



CHAPTER VII. 



Treatment of Irreducible Hernia. 

Ruptures are very often irreducible when they are 
not in a state of strangulation. The chief circumstances 
which prevent their return are an increase of bulk, and 
preturnatural adhesions to surrounding parts. Bands 
formed of coagulating lymph pass in some cases in va- 
rious directions through the hernial sac, and water in 
many cases collects in considerable quantity, rendering 
it necessary to tap the tumour for its evacuation. I have 
at this time a patient thus circumstanced ; he has a large 
scrotal hernia, and every month I draw off from it seve- 
ral pints of water. 

Irreducible herniae must in great measure be left to 
themselves. The inconveniences arising from the bulk 
are considerable, and there is constant danger of stran- 
gulation. This risk is diminished in many cases by the 
great dilatation of the ring, but it nevertheless exists, 
and should render the patient extremely cautious of all 
violent exertions, and he should especially guard against 
costiveness. A suspensory bag such as is used in cases 
of swelled testicle or hydrocele, will be found to 
obviate some of the unpleasant effects of the tumour. 

Cases considered as irreducible hernia have in some 
instances been gradually returned into the abdomen in 
consequence of long confinement to bed, and frequent 
purges, together with an adherence to an abstemious 
diet. In addition to these remedies, when the patient 
consents to employ them, moderate and increasing pres- 



ELEMENTS OF SURGERY. 49 

sure should be made upon the tumour by means of a 
sac of firm linen made so as to lace up to it in front. 

Irreducible herniaj should be carefully protected from 
accidental injuries, as the most serious consequences 
have sometimes resulted from blows upon such parts. 
And it is to be recollected that during the whole time of 
protrusion there is a risk of strangulation in consequence 
of any violent exertion. 

Patients afflicted with irreducible hernia are liable to 
indigestion and bowel complaints, from very slight causes, 
and therefore they ought to be extremely guarded against 
errors in diet ; they should also pay particular attention 
to prevent costiveness, by the use of clysters or laxative 
medicines when these become necessary. If, however, 
strangulation should take place in an irreducible rup- 
ture, it will generally be found to arise from an accumu- 
lation in the contents of the bowels, and therefore ca- 
thartic medicines and clysters very frequently relieve it 
without much difficulty. 



Vol. II. H 



50 ELEMENTS OF SURGERY. 

CHAPTER VIII. 

Treatment of Strangulated Hernia. 

The great object is, to replace the protruded parti 
in their natural situation within the abdomen, except in 
cases where they are probably mortified. The measures 
employed for this purpose are very various ; the princi- 
pal of which, are, the taxis — bleeding — the warm bath — 
clysters of tobacco — the application of ice or cold sub- 
stances to the tumour — opium — and cathartics. 

I. OF THE TAXIS. 

By this term surgeons express the attempt to reduce 
a hernia by the hands. The operation consists in varied 
endeavours to push up the protruded intestines. The 
patient is generally placed in a recumbent posture. When 
the case is an inguinal or femoral hernia, the pelvis 
should be placed higher than the shoulders, and if pos- 
sible the patient should avoid straining, coughing, and 
every exertion of the abdominal muscles. 

" The position of the patient must also be regulated 
with a view to the opening, through which the parts have 
descended. Hence, in inguinal and crural hernia, the 
thigh should be bent, and rolled inwards, in order to 
relax the tendon of the external oblique muscle. It is also 
recommended to elevate the shoulders slightly, as well 
as the pelvis. This brings the trunk into a curved state, 
and completely relaxes the abdominal muscles. Since 
the position now described is the most favourable to the 
return of the protruded parts, it should be continued, as 



ELEMENTS OF SURGERY. 5i 

nearly as circumstances will admit, until the rupture is 
replaced. 

"When things arc thus prepared, the surgeon begins 
his attempt by a gentle pressure on the tumour, which 
may be gradually increased, but should not be carried to 
such an extent as to cause pain : violence cannot indeed 
be beneficial, as it is more likely to press the parts in a 
mass against the ring, and thereby bruise and injure 
them, than to urge them through the opening. 

" Numerous instances are recorded, in which this un- 
scientific roughness has produced the most injurious con- 
sequences. Suppuration of the omentum, and gangrene 
or rupture of the intestine, have been its more immediate 
or remote consequences : and the danger of the subse- 
quent operation must be greatly increased, if the attempts 
at reduction are ineffectual. 

" We usually grasp the tumour with one hand, while 
the other is placed at the aperture, where it may be em- 
ployed in facilitating the entrance of the parts, and in 
keeping up those which have been already returned. 
Success will often be obtained by exerting a general 
pressure on the whole surface of the swelling; in which 
method both hands must be employed, in order to sub- 
ject the entire tumour to the action of the force. This 
method is strongly recommended by Petit. 

"The pressure should be exerted according to the 
course in which the parts have been protruded : thus, 
the contents of a bubonocele pass obliquely downwards 
and inwards ; those of a femoral rupture downwards and 
i hen forwards ; yet we should not confine ourselves en- 
tirely to such a kind of pressure as the course of the her- 
nia would suggest ; but in failure of those attempts, make 
other trials in different directions. 

"The following manoeuvre will sometimes succeed in 
a bubonocele or scrotal hernia, after the more ordinary 
methods have failed particularly in cases where the 



52 ELEMENTS OF SURGERY. 

strangulation seems to have been caused by an accumu- 
lation to fecal matter. Let the surgeon embrace the neck 
of the swelling, close to the tendon, with the finger and 
thumb of one hand, and carry them down with a mode- 
rate pressure, so as to remove the contents from the por- 
tion next the ring ; this will reduce the size of that part, 
which he may then attempt to pass into the ring with the 
other hand. Indeed, since the obstacle exists at the 
mouth of the sac, reduction will in general be more 
easily effected by pressing the upper part of the tumour 
towards the ring, than by exerting a general pressure 
over the whole swelling. 

" The return of a piece of intestine is generally pre- 
ceded by a peculiar noise, caused by the passage of air 
through the strictured part. It recedes at first gradually, 
and then slips up suddenly. The omentum goes up slowly 
to the very last portion, which must be actually pushed 
through the opening. 

" If the taxis should not succeed at first, it may often 
be successfully repeated after the use of the warm bath, 
bleeding, or cold applications. 

" The surgeon is not wan-anted in relying on the taxis 
as his chief method of accomplishing reduction ; he should 
not waste in unavailing efforts of this kind, that time 
which ought to be devoted to the prosecution of more 
vigorous measures. When he cannot reduce a rupture 
at one fair trial, he has less and less chance of effecting 
this object in the subsequent progress of the case, unless 
-he can produce an alteration in the state of the tumour 
by other means. 

(i Mr. Wilmer, of Coventry, has suggested a plan which 
should be noticed in this place. He proposes to make 
pressure by means of a weight left on the part for several 
hours. It succeeded with him in two cases. A two pound 
leaden weight was employed in one of these, and a com- 
mon smoothing iron in the other. If the swelling were 



ELEMENTS OF SURGERY. 58 

free from pain, and the circumstances not urgent, there 
could be no objection to a trial of this method. 

" After the reduction is accomplished, great care should 
be taken to avoid all irritation of the bowels, a mild ca- 
thartic should be employed to cleanse them." (Law- 
rence.) 

ii. of blood-letting. 

If the taxis should prove unsuccessful, blood should 
be drawn from the arm. Surgeons of the greatest re- 
spectability differ as to the propriety of this measure. 
Having never witnessed any ill effects from it, but on the 
contrary, having frequently seen it successful, I have no 
hesitation in recommending it. The quantity of blood 
to be drawn, should be sufficient to produce considerable 
sensations of weakness, and if possible, a tendency to 
syncope ; to effect which, the stream of blood should be 
large, and the patient's head should be propt up during 
the operation. 

Mr. Cooper remarks, " that a person unaccustomed to 
the small thready pulse of a patient suffering under stran- 
gulated hernia, feels apprehensive of taking away blood, 
conceiving the patient's strength to be fast sinking, but 
this fear is groundless, as the pulse becomes larger after 
this evacuation." The cold extremities, pale counte- 
nance, and weak respiration, of the patient, are also re- 
lieved rather than augmented by the operation. If syn- 
cope occur, it affords a favourable opportunity for at- 
tempting the reduction by the taxis. 

III. THE WARM BATH. 

Should the hernia not be reduced by this attempt, the 
natient is to be placed in a warm bath, the temperature 

»out one hundred degrees, and 



54 ELEMENTS OE SURGERY. 

should be gradually raised till the patient become^ 
fainty, at which time the taxis should be again tried. 

" The warm bath is used with views partly analagous 
to those which guide the practitioner in the employment 
of venesection, it induces a state of faintness and relaxa- 
tion under which the reduction may be attempted with 
advantage. The weakness produced by this remedy is 
temporary, and is not attended by any subsequent de- 
bility." 

IV. THE TOBACCO CLYSTER. 

The tobacco clyster is the next remedy to be employ- 
ed; the most convenient mode of preparing it is by 
infusing a dram of tobacco in a pint of boiling water 
for ten minutes — one half of which may be injected first 
and the remainder in twenty or thirty minutes if neces- 
sary. The quantity can be still further increased if the 
remedy prove inefficient, but extreme caution is neces- 
sary in the employment of this powerful medicine. Mr. 
Astly Cooper witnessed the death of a patient to whom 
two drams had been administered as a clyster. In anoth- 
er case related by the same author, a girl had a single 
dram injected ; « it produced violent pain of the abdo- 
men with vomiting, in which was thrown up a matter 
which smelt strongly of tobacco, and she died in thirty- 
five minutes after the clyster had been administered, 
most evidently from its effects." Mr. Cooper adds, that 
" when the tobacco acts in the manner to be desired, it 
produces extreme languor, a weak and quick pulse', a 
cold sweat, and such universal relaxation that the pa- 
tient has not power to exert any of the voluntary muscles 
of the body. In this stale, the hernia will often return 
into the abdomen with a slight pressure, though it has 
previously resisted a considerable degree of force." 



ELEMENTS OF SURGERY. 55 



V. COLD APPLICATION'S. 

The next powerful remedy to be employed is cold. 
The mode of using it is by applying pounded ice or 
told water in bladders to the tumour. Certain salts 
which in dissolving, occasion great degrees of cold, may 
be substituted, when ice is not to be procured. A solu- 
tion of sal ammoniac and nitre in equal parts answers 
very well ; ten ounces of this mixture may be dissolved 
in sixteen ounces of water. Mr. Wilmer has very strong- 
ly recommended the application of cold, and I am happy 
to state that I have in several cases found it complete- 
ly successful. In the employment of ice care should 
be taken not to freeze the skin, an accident which oc- 
curred to a patient under the care oi* Mr. CLue and Mr. 
8 harp. 

VI. OPIUM. 

Opium is often beneficial ; it allays vomiting, and some- 
times appears to be instrumental in effecting the redac- 
tion. After passing an hour in fruitless attempts to re- 
duce an inguinal hernia, I gave the patient at midnight 
a large dose of laudanum, and left him, expecting to per- 
form a surgical operation for his relief in the morning — 
I found next day to my surprize that the patient had 
slept soundly, and that during sleep the protruded in- 
testine had returned into the abdomen. A second case 
somewhat similar has since occurred. 

VII. CATHARTICS. 

Cathartics are by most surgeons laid aside in the treat- 
ment of strangulated ruptures. There are cases, how- 
ever, in which they appear proper, and these are cases 



56 ELEMENTS OF SURGERY. 

in which the strangulation takes place slowly, and the 
bowels appear loaded with fecal matter. Whenever 
vomiting occurs, medicines taken by the mouth generally 
increase it and do no harm. The best cathartic I have 
seen employed is a combination of jalap and cream of 
tartar. In omental hernia purges are generally useful 
when the stomach can retain them. 

The following remarks of Mr. Lawrence on the em- 
ployment of the preceding remedies are extremely judi- 
cious. 

" It may be expected, that these observations on the 
various modes of treating strangulated hernia should be 
applied to cases as they actually occur ; but this must be 
done by the surgeon in his practice. He should endea- 
vour to ascertain the cause and species of the incarcera- 
tion ; and he must exert his own judgment in the selec- 
tion of his means, and their adaptation to the circum- 
stances of the case. If he is called in the early state of 
the complaint, and the taxis has been unsuccessful, 
warm bathing and blood-letting, where the circumstances 
admit of it, will be the first means for him to employ. 
I should not, however, be inclined to recommend the 
warm bath, unless it can be prepared expeditiously. 

" Cold applications to the tumour hold the next rank 
in the list of remedies. Should these be unsuccessful, 
he will give a fair trial, with as little delay as possible, 
to the tobacco ; and, in the event of its failure, imme- 
diately operate. 

" When as it very frequently happens, the aid of the 
surgeon is not required until the complaint has lasted 
for some time, a trial of the tobacco, together with the 
topical use of cold, should be immediately resorted to ; 
as circumstances will not admit of delay in the previous 
use of less powerful remedies. His own discernment 
must be trusted for adapting his means and conduct to 



ELEMENTS OF SURGERY. % 5*7 

the different circumstances of an inflammatory and a 
chronic case. The use of purgatives and clysters, v, hich 
are beneficial in the latter, do not afford a chance of suc- 
cess in the former description. They should never be 
employed, unless the slow progress of the case clearly 
shows that the danger is not urgent. 

" I wish to impress the surgeon with the propriety of 
giving, without delay, an adequate trial to the most pow- 
erful means which the art affords, and of performing the 
operation as soon as it can be clearly perceived that these 
are unsuccessful. There is no reason to expect that a less 
active remedy will succeed, when a more potent one has 
failed. The chance of reducing a rupture is lessened in 
proportion to the duration of the complaint; the pro- 
lapsed parts becoming more inflamed, are more closely 
pressed by the stricture, and soon fall into a state where 
attempts at reduction by the hand are inadmissible." 

The dangers resulting from delaying the operation too 
long, have been clearly inculcated by all the late writers 
on hernia. Mr. Hey's very candid account of his own 
timidity and its consequences, is a striking comment upon 
the subject ; he says that he lost three patients in five, 
when he first began business. Having more experience 
of the urgency of the disease, he made it his custom, when 
called to a patient, who had laboured two or three days 
under the disease, to wait only about two hours, that he 
might try the effect of bleeding, (if that evacuation was not 
forbidden by some peculiar circumstances of the case) and 
the tobacco clyster. In this mode of practice he lost about 
two patients in nine, upon whom he operated. This com- 
parison is drawn from cases nearly similar, leaving out 
of the account those cases in which gangrene of the intes- 
tine had taken place. "I have now," he adds, "at the time 
of writing this, performed the operation thirty-five times ; 
and have often had occasion to lament that I performed it 
Vol. IT I 



58 ELEMENTS OF SURGERY. 

too late, but never that I had performed it too soon." It 
is unfortunate that no mode of ascertaining, from the 
symptoms which occur, the proper time for operating 
has yet been pointed out. It would be very import- 
ant for the surgeon to ascertain the latest period to which 
his operation could be postponed. It has been supposed 
that the occurrence of hiccough denotes the commence- 
ment of mortification ; but for this opinion there is no 
ground, since it often takes place before gangrene comes 
on, and is often absent when the intestines are mortified. 
Mr. Cooper says, that he is always anxious to perform 
the operation before the abdomen becomes sore to the 
touch : — he does not allude to the tension of the abdomen 
which occurs soon after strangulation, but to a pain aris- 
ing from pressure on the belly, which denotes that its 
contents and lining membrane are inflamed, in which 
case death generally follows the operation. 

A fair trial therefore of the remedies already described, 
having been made, the operation of liberating the stran- 
gulated intestine by the knife should be promptly per- 
formed ; the modes of doing it will be described here- 
after. 

Most of the preceding observations refer to hernia 
generally. — We proceed next to speak of particular 
ruptures. 



ELEMENTS OF SURGERY. 59 



CHAPTER IX. 



Of Inguinal Hernia. 

Inguinal hernia, and sc/rotal hernia, are that spe- 
cies of rupture in which the protruded viscera pass out 
at the abdominal ring. It is inguinal hernia whilst the 
tumour is confined to the groin, in which situation it is 
also called bubonocele ; it becomes scrotal hernia when 
it descends so low as to be covered by the integuments 
of the scrotum. In women it forms a tumour in one of 
the labia pudendi. 

It is impossible to communicate correct ideas of this 
disorder to a person unacquainted with the anatomy of 
the parts affected. Mr. Astly Cooper has bestowed a 
great deal of labour in investigating and describing the 
important structure of the abdominal ring, and the parts 
in its vicinity ; he has illustrated his descriptions by very 
accurate and very splendid engravings, taken from ac- 
tual dissections, and in this manner has laid before the 
public one of the most useful and instructive volumes of 
which modern surgery can boast.* 

To Mr. Cooper's book, and to the dissecting room I 
refer for the anatomy of these parts, contenting myself 
with one or two remarks. The aperture through which 
the parts descend in this species of hernia, is not to be 
considered as a ring, or hole, but as a passage or canal, 
the internal extremity of which, is the part where the 
spermatic vessels leave the abdomen, which is generally 

* Engravings have also been published by Simmering from drawings by 
Camper, and more recently by Scarpa, illustrative of the anatomy of hernia 
whjch have great merit. 



60 ELEMENTS OE SURGERY. 

One inch .and a quarter distant from the abdominal ring* 
the inner margin of the opening being almost invariably 
half way between the spinous process of the ilium and 
the symphysis pubis ; through this opening and through 
the abdominal ring, the spermatic cord passes down in 
the male subject to the testis. 

The following description of the complaint is extract- 
ed from Mr. Cooper's treatise. 

Inguinal hernia makes its first appearance In the 
form of a small tumour, situated about an inch and a half 
to the outer side of the abdominal ring, in a line extend- 
ing from the pubis to the anterior superior spinous pro- 
cess of the ilium. 

If its progress is interrupted, it proceeds gradually 
obliquely downwards, and inwards, in the direction of 
the spermatic cord as far as the abdominal ring. 

As long as it remains above the ring its existence is 
often unsuspected by the patient, because it requires a 
careful examination to detect it ; but to a surgeon ac- 
quainted with the natural feel and appearance of the 
parts it is sufficiently obvious. The length of the swell- 
ing above the ring will be found the same as the part of 
the spermatic cord included between the upper opening 
and the abdominal ring ; that is, about an inch and a half 
in the adult subject. 

The tumour next descends through the abdominal 
ring into the scrotum (here taking the name of scrotal 
hernia,) and being now less confined than before, it 
forms a distinct swelling, sufficient to awake the pa- 
tient's attention, who now, generally for the first time, 
is led to require surgical assistance. As the growth of 
the tumour, when in the scrotum, is little restrained by 
external pressure, it increases to an almost unlimited, 
and sometimes enormous size. One of the largest of these 
swellings which is recorded, occurred in a man who 
was sent to Guy's Hospital by Mr. White, surgeon at 
Lambeth, It reached to the patient's knees, its length 



ELEMENTS OF SURGERY. 61 

Was twenty-two inches, and its circumference thirty-two. 
Another measurement taken by Mr. White when it had 
been for some hours strangulated, gave thirty-four inches 
for the circumference, and twenty- two for the length. 

When an inguinal hernia is dissected, immediately 
under the skin of the scrotum is found a fascia of greater 
or less thickness according to the duration and size of 
the tumour. This fascia is given off by the tendon of 
the external oblique muscle above the abdominal ring. 
In general, it appears little more than a condensed cel- 
lular membrane, but in old hernias it becomes as dense 
as the fascia that covers the muscles on the outer part of 
the thigh. 

Under this fascia is the cremaster muscle, which 
forms another covering to the hernial sac ; for this mus- 
cle, in passing down through the abdominal ring, is 
united both to the fascia and to the sac, separable from 
both, however, by an easy dissection. This muscle be- 
comes much more extended and thicker in hernia, than 
in the natural state. 

When the fascia and cremaster muscle are removed, 
the proper hernial sac becomes exposed to view. This 
is thinner than the two former coverings, but somewhat 
thicker than the peritoneum from which it is immediately 
derived. Many writers have represented the sac as 
much denser than it really is, mistaking the two above 
coverings for the sac itself. 

Behind the hernial sac lie the spermatic cord on the 
upper part, and the testicle on the loAver ; so that the 
sac is situated between the cord and the cremaster mus- 
cle, anterior to the former and posterior to the latter. 
The direction of the hernia above the abdominal rins is 
obliquely upwards and outwards towards the spine of 
the ilium, the same as that of the spermatic cord. Above 
the ring, the hernial sac is covered by the tendon of the 
external oblique muscle : the spermatic cord is still be- 



62 ELEMENTS OF SURGERY. 

hind it, and further backwards are the tendons of the in- 
ternal oblique and transversalis muscles and the fascia 
before mentioned. At the upper aperture in the fascia, 
the sac penetrates the abdomen along with the spermatic 
cord. This part is called its mouth, and is generally, 
though not always, its narrowest dimension. Between 
the mouth of the sac and the symphysis pubis passes the 
epigastric artery. This vessel runs in some degree un- 
der the sac, and along its inner side. There is no ves- 
sel of importance above the mouth of the sac, nor exter- 
nally, that is, between it and the spinous process of the 
ilium. 

The relative situation of the hernia with the abdomi- 
nal openings above described, applies only whilst it re- 
mains of small size ; for when hernia has existed a con- 
siderable length of time, and has carried with it a large 
portion of abdominal viscera, the constant pressure di- 
lates the parts in each direction, extending the opening 
through which it passes from the abdomen, both towards 
the spine of the ilium, and especially towards the sym- 
physis pubis. Hence it is, that in old and large hernia, 
the orifice of the sac into the abdomen is brought to be 
almost in contact with, and opposite to, the abdominal 
ring. 

It has been stated that the hernial sac in its descent 
is anterior to the spermatic cord. This is its most fre- 
quent situation, but varieties occur in this respect which 
the surgeon should keep in mind during the operation, 
and the cord is sometimes found separated, and the her- 
nial sac protruded between its vessels. 

The inguinal hernia is very generally pyriform, 
small towards the ring, and enlarging as it descends. 
It occurs much more frequently on the right than the 
left side. 

The circumstances whereby this disease may be dis- 



ELEMENTS OF SURGERY. 68 

tinguished frtfm other tumours with which it is liable to 
be confounded, are the following : 

First, When the patient is desired to cough, the tu- 
mour becomes immediately distended, owing to the pres- 
sure of the abdominal muscles forcing down into the sac 
more of the viscera or their contents. 

Secondly, When the patient can state from his remem- 
brance, that on the first appearance of the tumour in the 
groin, it had used to return into the abdomen when he 
was in a horizontal posture, and to re-appear on stand- 
ing erect ; though circumstances may have long prevent- 
ed this symptom from continuing. 

Thirdly, When the progress and the tumour has been 
from the groin gradually downwards to the scrotum. 

Fourthly, When the tumour contains intestine, it is 
clastic and uniform to the touch ; and on being pushed 
up into the abdomen, it returns with a guggling noise. 
But when omentum is contained, the tumour is less equal 
on its surface, receives an impression from the fingers, is 
heavier than in the former case, and does not make the 
same noise when returned into the abdomen. Most com- 
monly, however, both intestine and omentum are the con- 
tents of the hernia ; a circumstance which impairs the 
accuracy of any very nice distinctions by the touch ; 
though still on pushing back the contents of the tumour, 
the presence of intestine, which returns the first, will 
often be indicated by the guggling noise, whilst the more 
solid omentum may be felt going up after it. 

Lastly, The functions of the viscera are somewhat in^ 
terrupted. Eructations, sickness, constipation, colicky 
pains, and distention of the abdomen occur ; and pain is 
produced by violent exertions, coughing, or sneezing. 
These are the symptoms that generally give the patient 
some suspicion of the nature of the complaint. 

However there are several diseases of the groin and 
scrotum with which hernia is liable to be confounded t 



64 ELEMENTS OF SURGERY. 

so that these are few surgeons who have seen much of her- 
nia, who have not frequently witnessed mistakes, made 
even by medical practitioners, which have led to the ap- 
plication of trusses in diseases where they not only are 
useless, but even productive of much injury. The repu- 
tation of the surgeon, and the safety of his patients, re- 
quire of him a very accurate attention to this point. 

A hydrocele of the tunica vaginalis testis resembles 
hernia in its form, but may he distinguished from it by 
the following marks : 

The hydrocele begins to form at the lower part of 
the scrotum, and gradually extends towards the ring. It 
also involves the spermatic cord and testis, so as to ren- 
der them with difficulty distinguished by the touch ; 
whilst in hernia they may in general be felt with ease 
behind the tumour. Hydrocele gives a fluctuating feel 
when struck with the fingers,, does not become dilated 
when the patient coughs, and appears considerably trans- 
parent when a lighted candle is held by its side. 

There are cases of hydrocele, however, in which 
there is unusual difficulty in deciding upon the nature 
of the complaint. When it becomes so large as to ex- 
tend upwards through the abdominal ring to the abdo- 
men, the form of the tumour is precisely the same as that 
of hernia, and it even dilates when the patient coughs, 
owing to the sudden pressure upon that part of it which 
lies above the ring. The transparency, the fluctuating 
feel, and the observed progress of the swelling from be- 
low upwards, are then the only distinguishing marks. 

A tumour sometimes appears in the scrotum, which 
descends in the erect posture, returns when the body is 
recumbent, distends upon coughing, fluctuates^ and is 
transparent. This disease is a collection of water which 
runs backwards and forwards from the cavity of the ab- 
domen within the tunica vaginalis, owing to the opening 
of this membranous sheath never having been closed 



ELEMENTS OF SURGERY. 65 

When this disease is complicated with ascitesit becomes 
distended to an enormous size. It is readily distinguish- 
ed from hernia from its transparency, which may always 
be observed. 

Water sometimes collects in a cyst upon the spermatic 
cord, forming a hydrocele of the cord. When it is placed 
entirely below the ring, its want of connexion with the ab- 
domen readily distinguishes it from hernia ; but when 
it passes within the ring to the abdomen, some difficulty 
occurs in understanding its nature. If from its situation 
the transparency cannot be examined, and if the fluctu- 
ation is not very distinct, a surgeon should be very cau- 
tious in operating on such a tumour. 

Nothing but great want of attention can cause a her- 
nia to be confounded with an enlargement of the testis. 
This latter is sufficiently- distinguishable by the form of 
the organ, which is retained under morbid enlargement, 
by its weight, by the pain with which it is generally ac- 
companied, and by that peculiar and intolerable sensa- 
tion always produced by pressure upon this part. 

Hematocele, or a collection of blood in the tunica 
vaginalis testis, as it generally arises from a blow, is of 
the same form as hernia, and liable to be confounded 
with it. But the firmness of hematocele, the redness of 
the skin with which it is accompanied, its refusing to 
dilate under coughing, and freedom from swelling of the 
spermatic cord at the abdominal ring, which is generally 
the case, will usually aflbrd the means of distinction 
from hernia. 

But of all the diseases of the scrotum, which are 
mistaken for hernia, none is so much so as the varicocele* 
or enlargement of the spermatic veins. Mr. Cooper has 
known persons (even the children of medical men) to 
wear trusses for a supposed hernia, which they complain- 
ed did not fit, gave them pain, and could not prevent the 

• By varicocele Mr. Cooper means the disease more properly denominated 
cirsocele. 

Vol. H. K 



66 ELEMENTS OF SURGERY. 

descent of the tumour, when it was found that the disease 
was this enlargement of the spermatic veins. 

Varicocele has indeed many of the marks of hernia. 
When large it dilates upon coughing, but not otherwise; 
it appears in the erect position, and retires when the body 
is recumbent ; and it is first observed near the ring. The 
only sure method of distinction according to Mr. Coop- 
er is to place the patient in the horizontal posture, 
and empty the swelling by pressure upon the scrotum, 
then putting the fingers firmly upon the upper part of the 
abdominal ring, desire the patient to rise : if it is a her- 
nia, the tumour cannot re-appear as long as the pressure 
is continued at the ring ; but if a varicocele, the swelling 
returns with increased size, owing to the return of blood 
into the abdomen being prevented by the pressure. 

Some judgment may also be formed by the feel of 
the tumour, for that of varicocele is always ropy, as if 
a bundle of cords were contained within the scrotum. 

There are, however, some cases of a complicated 
nature which demand much judgment and accurate dis- 
crimination. For instance, hernia is sometimes compli- 
cated with hydrocele of the tunica vaginalis ; and some- 
times the sac contains omentum, adhering to its upper 
part, and a collection of water below. If the adhesion 
of the omentum is complete, there is no danger of at- 
tempting the cure of the hydrocele by injection ; however, 
if the case clearly appears to be of this kind before ope- 
ration, it is best to use the method of incision. 

OPERATION FOR INGUINAL HERNIA. 

Having already described the means to be employed 
for the reduction of inguinal hernia, it remains to describe 
the operations which become necessary, when the stran- 
gulated parts cannot by these measures be returned. 



ELEMENTS OF SURGERY. 67 

The object of a surgical operation in the present case 
is to replace the protruded bowels, if they be not gangre- 
nous, and to remove such portions as may be mortified. 

The patient should be placed upon a common dining 
table, Avith his legs hanging over its end, his shoulders 
and knees being a little raised by pillows in order to 
relax the abdominal muscles. The bladder should be 
emptied. 

The hair being removed from the pubes, an incision 
should be made with a common scalpel through the skin 
and cellular membrane, beginning an inch from the ab- 
dominal ring, in the direction of the fibres of the exter- 
nal oblique muscle, and extending nearly, or in small 
hernise, quite to the bottom of the tumour. The external 
pudental artery is generally divided by this incision, but 
seldom requires a ligature ; if it bleed so as to incom- 
mode the surgeon, an assistant may compress it with his 
linger, or if necessary, the surgeon can take it up with a 
tenaculum and ligature. 

If the operation be performed in a case in which it 
would be desirable to return the parts, if practicable, by 
the taxis ; that is to say, if no symptoms of gangrene be 
present, then the operation should be conducted in the 
following manner : the abdominal ring, and the portion of 
the tendon forming it, should be exposed ; a small hole 
should be scratched through the tendon half an inch from 
the ring, in a direction upwards and outwards, towards 
the spine of the ilium ; a director should be passed 
through this hole under the tendon and out at the ring ; 
when this is done, a bistoury or scalpel should be passed 
along the groove of the director so as to divide the ten- 
don. If the stricture have been caused by the abdomi- 
nal ring, it will in this manner be removed, and the pro- 
truded parts can be easily returned into the abdomen. 
If the stricture be seated higher up than the ring, and 
the parts can be pushed up without violence by the finger, 



68 ELEMENTS OF SURGERY. 

it ought now to be done, without opening the sac. This 
very simple and easy operation has in a variety of cases, 
in Dr. Physick's practice, succeeded completely in ef- 
fecting a cure ; the after treatment is very simple, and 
the patient experiences very little inconvenience, as the 
wound speedily heals, and no danger of peritoneal in- 
flammation follows. 

This practice of not opening the. sac is ascribed by 
Mr. Lawrence to Petit. Mr. Lawrence thinks it ought 
to be employed more frequently than it is, and Dr. Mon- 
ro's testimony is also in its favour ; having seen it al- 
most uniformly successful I have no hesitation in recom- 
mending it ; I am aware of the objections which have 
been urged against it, but I rest its defence upon the 
question, whether it would have been proper, before 
commencing the operation to have returned by the taxis 
the prolapsed parts ? If so, it cannot be more necessary 
to expose the contents of the sac, after the stricture has 
been divided. If after reducing the hernia, the sac can 
also be returned into the abdomen (which is but seldom 
practicable) this ought to be done. 

It is extremely important, however, to bear in mind 
the necessity of opening the sac, in all cases where there 
is any reason to apprehend gangrene in its contents, or 
adhesions which will prevent their reduction. 

Mr. Astly Cooper directs the external fascia which 
proceeds from the tendon of the external oblique muscle 
to be exposed by a free incision through the skin and 
cellular membrane; this fascia forms the thickest cover- 
ing of the sac; the middle of it is to be next cut through 
and a director introduced beneath it, upon which it is to 
be divided, upwards towards the abdominal ring, and 
downwards to the bottom of the tumour. This opening 
through the fascia exposes the second covering of the 
hernial sac, viz. the cremaster muscle which must be 
divided precisely in the same manner, when the sac 



ELEMENTS OP SURGERY. 69 

will be exposed. " It should be remarked that to those 
not accurately acquainted with the anatomy of the parts, 
the division of these layers causes great embarrassment 
and delay, for the operator expecting to see the sac it- 
self as soon as he has divided the common integuments, 
cuts the fascia with extreme caution, fibre after fibre, 
from fear of injuring the intestine beneath, mistaking 
this thickened covering and the cremaster muscle for the 
hernial sac. 

" When the sac is completely exposed, if the hernia 
is intestinal, and the intestine does not adhere to the sac, 
a sense of fluctuation may generally be perceived at its 
anterior and inferior part, when the tumour is grasped, 
and the fluid which it contains is pressed forward. 

" The surgeon is next to pinch up some of the cellular 
membrane which closely adheres to the anterior and in- 
ferior part of the sac, by means of a pair of dissecting 
forceps, and when the sac is thus raised, and separated 
from the intestine, he is to place the edge of the knife 
horizontally, and to cut a small hole just sufficiently 
large to admit the blunt end of a probe or that of a di- 
rector, upon which the sac is to be further divided, be- 
ing cut upwards to within an inch of the abdominal ring, 
and downwards to the bottom of the sac. The reason 
that the anterior and inferior part of the sac is selected 
for the first incision into it is, that the intestine seldom 
descends so low, and if it does, the fluid which it con- 
tains is generally found interposed between the intestine 
and that part of the sac. The sac should not be divided 
higher than to an inch below the abdominal ring, as its 
division near the abdomen makes it more difficult to 
close the wound, and exposes the patient to the danger 
of peritoneal inflammation. 

" As soon as the sac is opened, a quantity of fluid es- 
capes ; its colour, if the strangulation has not been long 
continued, is that of serum, but if the intestine has been 



70 ELEMENTS OF SURGERY. 

for a long time compressed, it becomes of a cotfee co- 
lour, and sometimes offensive to the smell. Its quantity, 
if there is no adhesion of the intestine *to the sac, is pro- 
portioned to the quantity of intestine strangulated, for if 
adhesion exists, little, if any is found, so that the sur- 
geon who depends on meeting with if, would wound the 
intestine in the operation. In the omental hernia also 
there is seldom any fluid in the sac, and if any, a com- 
paratively small quantity ; for this fluid seems to be prin- 
cipally a secretion from the surface of the intestine. 

" When the sac is opened, the contents of the hernia 
appear ; and if both the intestine and omentum have de- 
scended, the latter is the first that presents, and general- 
ly covers, and sometimes entirely envelopes the intes- 
tine. The omentum retains much of its usual appear- 
ance, its colour being only a shade darker than natural ; 
but the intestine is covered with a coat of coagulable 
lymph, and appears red if it has not been long strangu- 
lated ; but of a chocolate brown colour if the stricture has 
been very tight, or the strangulation long continued. 
The veins upon it are turgid with blood, and I have seen 
the lacteals upon the jejunum and ileum distended with 
air. 

" The next part of the operation is the division of the 
stricture, and the surgeon carries his finger into the her- 
nial sac to examine accurately into its situation, which 
he will find in one or other of the three following parts. 

" First, at the abdominal ring. 

" Secondly, above the ring from one inch and a half 
to two inches, and inclining outwards toward the spi- 
nous process of the ilium. 

" Thirdly, in the mouth of the hernial sac. 

" If the stricture is owing to the pressure of the co- 
lumns of the tendon which form the abdominal ring, it is 
then to be divided in the following manner. The sur- 
geon passes his finger into the sac as far as the stricture. 



ELEMENTS OF SURGERY. 71 

and then conveys a probe-pointed bistoury on the fore 
part of the sac, and to sin extent proportioned to the size 
of the tumour. The dilatation of the ring should not 
be larger than is sufficient to return the protruded parts ; 
but it should allow them to pass without committing any 
violence by the pressure exerted in effecting a return. 
In general, if the finger can be readily admitted into the 
abdomen, by the side of the protruded parts, the dilata- 
tion is sufficiently free. 

"It is best to divide the stricture by passing the knife 
between the ring and the sac, as a larger portion of pe- 
ritoneum is thus left uncut, and the cavity of the abdo- 
men is afterwards more easily closed. The direction 
given to the knife in dilating the stricture has been usu- 
ally upwards and outwards towards the spine of the 
ilium, but I prefer doing it directly upwards, for the two 
following reasons. 

"First, as the higher aperture must only be dilated 
directly upwards, it is better that the surgeon should 
have one general rule for the use of the probe-poimed 
bistoury, applicable to every case of inguinal hernia, 
than to be perplexed in the operation by a variety of di- 
rections, which only partially apply to one or other seat 
of the stricture ; and secondly, the division of the tendon 
in this direction weakens the abdomen less than up- 
wards and outwards, because as the cord passes towards 
the abdomen in that direction, and the hernial sac is pa- 
rallel with the cord, a dilatation in that course takes off 
the resistance which the tendon would otherwise make 
to any future descent. When the ring is divided direct- 
ly upwards, the upper column of the tendon which forms 
it is cut, when it is dilated upwards and outwards, the 
transverse fibres uniting the columns, are divided. The 
dilatation upwards is equally safe with the other, for if 
this Were not the case, no subordinate advantage ought 
to interfere with the most important one of security. 



72 ELEMENTS OF SURGERY. 

« A frequent situation of the stricture, however, is not 
at the abdominal ring, but at the place at which the sac 
opens into the abdomen, that is an inch and a half or 
two inches above, and to the outer side of the ring : and 
it is there occasioned by the pressure of the tendon of 
the transversalis which passes over it, and by the resis- 
tance of the border of fascia which passes under it. 

" If the stricture is at this orifice it is to be divided as 
follows : The surgeon passes his finger up the sac, and 
through the abdominal ring, until he meets with the 
stricture ; he then introduces the probe-pointed bistoury 
with its flat side towards the finger, but anterior to the 
sac, and between it and the abdominal ring, his finger 
being still a director to the knife. Thus he carries the 
knife along the fore part of the sac until he insinuates it 
under the stricture formed by the lower edge of the trans- 
versalis, and internal oblique muscles, and then turning 
the edge of the knife forwards, by a gentle motion of its 
handle he divides the stricture, sufficiently to allow the 
finger to slip into the abdomen : the knife is then to be 
withdrawn with its flat side towards the finger as it was 
introduced, to prevent any unnecessary injury of the 
parts. The direction in which this orifice is divided is 
straight upwards, opposite the middle of the mouth of 
the sac, as in this way the epigastric artery can scarcely 
be cut, whatever be its relative situation with respect to 
the sac. 

" An advantage is derived from dilating the stricture, 
without cutting the sac itself, for there is danger of 
injuring the intestine with the naked edge of the knife, 
which I have twice known to happen when the stricture 
was divided from within the sac ; in one case the patient 
died from the contents of the intestine escaping into the 
cavity of the abdomen. In the other the intestine was 
obliged to be retained in the sac, to allow of the escape 
of the faeces by the external wound. An additional ad- 



ELEMENTS OF SURGERY. 73 

vantage is derived from this mode of dilatation, vi£. that 
if by any mistake of the operator the epigastric artery 
is cut, as the peritoneum is undivided, the flow of blood 
would be immediately perceived, and then the vessel 
might be secured ; whereas if the sac is included in the 
incision, the artery would bleed into the abdomen and 
the consequences would be fatal, without the cause being 
known but by dissection. 

" The third seat of stricture is the hernial sac itself, 
from its becoming thickened or contracted ; but I have 
already said that it is not so frequent an occurrence as 
has been imagined, for the pressure of the surrounding 
parts above the ring has been often mistaken for it. It is 
however undoubtedly true, that it does sometimes occur." 
(Cooper.) 

Mr. Cooper adds, " that he had lately dissected a sub- 
ject, in which the peritoneum at the mouth of the sac was 
considerably thickened, and had pressed upon a portion 
of intestine which it included, so as to occasion its stran- 
gulation." 

I have myself seen a very singular case in which the 
stricture existed at the neck of the hernial sac : — A wair- 
onner who had a long time been afflicted with a scrotal 
hernia for which he had worn a truss, was attacked sud- 
denly with symptoms of strangulated rupture. I visited 
him and found a small hernial tumour, but so free was 
it from all appearance of strangulation, that I doubted 
vory much whether his symptoms were at all connected 
with it — the abdominal ring was an inch in diameter, 
and admitted freely the fingers to pass up, and the tu- 
mour could be pressed up, but immediately after re- 
turned. Suspecting a stricture at the upper aperture of the 
canal, I requested a consultation, and Dr. Physick was 
sent for ; all the usual remedies for the reduction of the 
hernia had been tried before I saw the patient, by a me- 
dical gentleman who had previously been caUed in 
Vol. II. L 



74 ELEMENTS OF SURGERY. 

Dr. Physick recommended that the hernial tumour should 
be opened, in order to ascertain whether it contained a 
strangulated intestine or not. This operation was per- 
formed, and upon cutting into the sac some dark colour- 
ed fluid escaped, but nothing else could be discovered 
in it. The finger apparently entered the cavity of the ab- 
domen, but touched nothing but the peritoneum ; at length 
the extremity of my middle finger came in contact with 
a piece of intestine, near the fundus of the bladder, and 
this appeared fixed in its situation : I succeeded however 
in pushing against it somewhat firmly, and it slipped up 
evidently out of a narrow aperture. 

The patient died a few hours after the operation, and 
upon dissection the nature of this obscure case became 
evident. An old hernial sac existed, which had been 
reduced and was now almost entirely within the abdo- 
men, a small process of it only extending through the 
abdominal ring. Into this hernial sac, a piece of the 
ileum had been forced, became strangulated, and was 
found mortified.* 

When the stricture is formed in this way by the 
neck of the sac, in whatever situation that may be, it 
should be divided by a careful use of a bistoury having 
only a small cutting surface near its extremity. f Such 
an instrument has been recommended by Mr. Cooper, 
but a good substitute may be made by covering a com- 
mon probe-pointed bistoury with waxed linen, except at 
its extremity, where a quarier of an inch of the ed°-e 
may be left bare. 

"When the stricture has been completely removed, the 
protruded intestine is to be attentively examined to ob- 
serve whether the brown colour which it assumes under 

* Several cases are recorded somewhat analagous to this j Mr. Cooper's sixth 
case of crural hernia in some respects resembled it, but in no case I have seen 
described, was there a stricture in the neck of an old hernial sac which had 
been a long time returned into the abdomen. The annexed sketch represent* 
the case I have described. 

f Mr. Cooper's bistoury is represented in the first plate of this volume. 



ELEMENTS OF SURGERY. 75 

strangulation lessens or disappears, as this is a proof of 
the return of circulation in the part. The veins on its 
surface may also be emptied by pressure, and their sud- 
den filling noted, and the intestine should be pulled 
down a little to make these observations on the part which 
has immediately been compressed by the stricture. If 
the intestine appears to have a free circulation the sur- 
geon should directly but gradually return it, thrusting 
up about an inch at a time, and securing each part with 
his fingers until the whole is returned into the abdomen. 
All violence and improper haste should be carefully 
guarded against; for the intestine is tender, and will 
easily tear at the strictured part." (Cooper.) 

If any difficulty is experienced in replacing the intes- 
tiue, the position of the patient should be the same as 
when the taxis is employed so as to relax the aperture 
into the abdomen. 

u If the intestine is connected with the sac by adhe- 
sion, an extraordinary degree of caution is required on 
opening the sac, as it contains no interposed fluids. If 
the bands which form the adhesion are long enough to 
allow of the intestine being drawn a little from the sac, 
they may be completely separated by dissection ; but if 
they are so short that the intestine and sac are aggluti- 
nated together, it becomes necessary to cut off portions 
of the sac, and to return them still adhering to the bowel, 
into the cavity of the abdomen. Sometimes the adhe- 
sion exists only at the orifice of the sac, all the lower 
part being perfectly free ; a circumstance which requires 
great caution in the operation to ensure the entire return 
of the protruded intestine, as otherwise the operation 
will fail of its object. 

" It sometimes happens that the convolution of intes- 
tine in the hernial sac has its sides glued together by 
recent adhesions. When this happens, it is right to se- 
parate them before the intestine is returned, because the 



if ii wn&w*i?W*Wgp' 



^6 ELEMENTS OF SURGERY. 

stools do not readily find their way through an intestine 
which is thus doubled. 

« It is an operation of extreme difficulty and delicacy 
to divide adhesions at the mouth of the hernial sac. It 
requires that the sac should be dilated to its mouth, and 
that the tendon of the external oblique should be slit up 
to the part at which the hernia descends from the abdo- 
men. Great danger of wounding the intestine, even when 
the parts are thus completely exposed, attends the divi- 
sion of the adhesions. 

" When the intestine has been returned, the omentum 
is to be examined with attention, and if it is in a healthy 
state, and not of very considerable bulk, it should be re- 
turned into the cavity of the abdomen by as slight a pres- 
sure as possible. But if it is very bulky, a part of it 
should be removed ; which may be done by the knife with 
great freedom, and if properly managed, without any 
danger. I have myself removed it in several instances 
without the patient seeming to suffer any subsequent in- 
convenience. The surgeon raising the omentum, whilst 
an assistant grasps it higher up to prevent its return into 
the abdomen, cuts it off near the mouth of the sac. Some 
small arteries always bleed, which are to be secured by 
a fine ligature ; and when the hemorrhage is stopped, 
the omentum is to be returned into the abdomen, with its 
divided surface applied to the mouth of the sac, from 
which the ligatures are suspended, and it thus forms a 
plug that shuts up its cavity. 

" The practice of applying a ligature round the whole 
of the protruded omentum, to make it slough away, though 
it has had its advocates, is now very generally laid aside. 
Indeed it appears extraordinary that it should ever have 
prevailed. The very object for hernia, is to take off 
from the omentum the stricture derived from the pressure 
of a surrounding tendon, which acts as a cord upon the 
part ; and no sooner is this removed, than the surgeon 



ELEMENTS OF SURGERY. 7 i 

applies a ligature, which produces a more perfect con 
striction than that which had previously existed. I have 
several times known the omentum tied, and the patient 
still recover ; but it appeared to me that its living powers 
had been already destroyed by the pressure of the stric- 
ture ; and if the part is mortified, a ligature cannot ex- 
cite constitutional irritation, or produce any dangerous 
consequences, but, on the other hand, its application is 
attended with no utility, as the omentum would have 
sloughed if the thread had not been used. 

(i If mortification has taken place in the omentum, it 
is to be removed by excision at the sound part, in the 
manner I have already described. Even if there is only 
suspicion, and not positive certainty of the omentum 
being mortified, it should be cut away ; as the removal is 
so far as I have seen, unattended with danger ; and its 
return into the abdomen, if mortified, or even approach- 
ing to, that state, is attended with the utmost hazard, and 
generally proves fatal. One exception, however, to this 
opinion, I have seen. A man underwent the operation 
for hernia in Guy's Hospital, and the sac was found to 
contain both omentum and intestine, which as they ap- 
peared not mortified, although considerably changed, 
were returned into the abdomen. On the sixth day after 
the operation the man appeared to be dying, his pulse 
was extremely feeble, and he complained of severe pain 
in the abdomen. The ligatures upon the scrotum were 
cut away, fomentations and poultices were applied to the 
wound, and on the following day a small portion of 
omentum protruded in a gangrenous state. More of it 
continued to come down, in this state, from time to time, 
during seven days, after which the whole portion which 
had been originally contained in the hernial sac, ap- 
peared in the wound, and gradually sloughed off. The 
wound then healed, and the patient recovered. This fa- 
vourable termination could only have happened in a case 



78 ELEMENTS OF SURGERY. 

in which the mouth of the hernial sac was wide, and 
where the omentum was lying in the abdomen just op- 
posite to its orifice. 

" If the omentum adheres to the sac, the adhesions may 
be cut through with considerable freedom, and the bleed- 
ing vessels being secured, the omentum should then be 
returned into the cavity of the abdomen. 

" It is sometimes necessary to cut away the omentum 
on account of its being in a scirrhous state. A case of 
this kind occurred in a man who was operated upon for 
a hernia congenita ; and the omentum being thus dis- 
eased, formed a large and hard tumour ; which is pre- 
served in the Anatomical Museum at St. Thomas's Hos- 
pital. 77 (Cooper.) 

In some cases in which the colon is prolapsed, the ap- 
pendices epiploicse protrude in a diseased state, in these 
cases they should be cut off ; no danger attends the ope- 
ration. 



ELEMENTS OF SURGERY. 79 

CHAPTER X. 

Of Mortified Intestine. 

Many of the following observations on mortified in- 
testine are extracted from Mr. Cooper. 

The symptoms by which this state of the intestine 
is known are, that the tumour which was tense and elas- 
tic becomes soft and doughy, and air can be felt crack- 
ling in the cellular membrane ; that its colour which was 
at iirst of a florid red, becomes purple. The hiccough 
and tension of the abdomen still continue, but the vomit- 
ing is less frequent. The pulse is intermittent, but ful- 
ler and softer than during the inflammatory state ; the 
eyis are glassy. The hernia now sometimes returns into 
the cavity of the abdomen without assistance, and the 
patient survives but a few hours : but sometimes the skin 
over the tumour sloughs, the intestine gives way, and 
the faeces being discharged at the opening, the symptoms 
of strangulation soon after cease. When this happens, 
the intestine contracts adhesions to the hernial sac. The 
portion which has been mortified sloughs away, and an 
artificial anus becomes established, through Avhich gene- 
rally during the remaining part of the patient's misera- 
ble existence, the faeces are constantly discharged. How- 
ever, it sometimes happens, when the intestine has slough- 
ed, that a re-union takes place of its extremities, the ex- 
ternal Mound gradually heals, the artificial anus is closed, 
and the faeces resume their natural course. 

The degree of danger which attends the artificial 
anus, depends upon the vicinity of the sphacelated in- 
testine to the stomach, for if the opening is in the jeju- 
num, so little space is left for the absorption of the chyle, 
that the patient dies from inanition. 



80 ELEMENTS OF SURGERY. 

When the artificial anus is in the ileum, it is attend- 
ed with less danger than in the jejunum. If it is situ- 
ated in the large intestines, patients scarcely appear to 
suffer in their general health, for Mr. Cooper has seen 
several instances of this disease in the colon, all of them 
in women, and from umhilical or ventral hernia ; and 
they seemed to possess the same bodily health with 
others, some of them being afterwards extremely corpu- 
lent. 

With respect to the treatment which is required 
in these cases of sloughing hernia, very little more 
can be done than to quicken the process of separa- 
tion by fomentation and poultice, and to support the 
strength by cordial medicines and bark : and any at- 
tempt made to lead the faeces into their natural course, 
prior to the sloughing being completed, will only irritate 
the parts, prevent the regular progress of separation, and 
endanger the destruction of the patient. When the ar- 
tificial anus is completely established, all that can be 
done is to lessen as much as possible the offensive state 
of the patient, by confining the faeces until it is conve- 
nient to discharge them. For this purpose a square 
cushion, covered with oiled silk, is to be placed over the 
artificial anus, and a steel truss, which exerts but a 
slight degree of pressure, being placed upon it, confines 
the faces so as to lessen the offensive smell, and allows 
the patient to seek a convenient situation for an evacu- 
ation. This plan answers extremely well if the feculent 
matter has some consistence, but if the aperture is in 
the ileum, the contents of this intestine are with difficulty 
confined. 

In performing the operation for strangulated hernia, 
if the intestine is mortified, the appearance which it as- 
sumes is that of a dark purple, or leaden coloured spot, 
or spots, which readily break down under the impress 



ELEMENTS OF SURGERY. 81 

sion of the finger. The other part of the intestine is of 
a chocolate brown colour, which has been often mistaken 
for mortification, but its colour and firmness prove that 
it has not advanced to that state. Every part of the sur- 
face of the intestine is covered by a layer of coagulated 
lymph, of a brown colour.* 

As the intestine cannot, when mortified, be returned 
into the cavity of the abdomen, the surgeon is to consi- 
der in what manner he is to proceed to save the patient 
from that most miserable state of existence, which is pro- 
duced by an artificial anus. In forming his judgment 
upon this subject, he will be directed by the state in 
which the part is found. 

If a small hole only has been produced, the intes- 
tine should be returned into the abdomen, excepting that 
portion of its cylinder in which the hole exists. A needle 
and ligature should be passed through the mysentery at 
right angles with the intestine, to prevent its including 
the branches of the mysenteric artery which supply that 
part of the intestine, and then through the mouth of the 
hernial sac ; and tying the thread, the intestine becomes 
confined to the mouth of the sac, and the faces pass rea- 
dily from the opening by the wound, but will in part take 
their course by the rectum. As granulations arise, and 
the wound becomes closed, the opening in the intestine 
is gradually shut, and an artificial anus is effectually 
prevented. 

When the whole cylinder of the intestine is morti- 
fied, it is necessary to proceed very differently. Then 
the mortified part of the intestine should be cut away, 
and the ends are to be brought in contact and confined 
by means of four ligatures." 

* One of the best tests of the mortification of a portion of intestine is the coagu- 
lation of blood in its vessels ; this is ascertained by pressure with the finger : 
if the colour disappears, and returns when the pressure is removed, it is not 
mortified, otherwise it most probably is. 

Vol. II. M 



82 ELEMENTS OF SURGEftY. 

From a number of experiments performed by Mr. A* 
Cooper and Mr. Thomson of Edinburgh, and by Dr. 
Smith in this city, it appears, that when the intestines 
of animals are stitched in this manner, the ligature 
passes through the alimentary canal with the faeces,* and 
the intestine heals very completely. Mr* Cooper infers, 
that the proper practice when an intestine is divided by 
mortification, is to cut off its mortified extremities, and 
" then to pass four stitches through them, one at the me- 
sentery and the three others at equal distances round the 
intestine ; then returning it to the mouth of the hernial 
sac, which should be opened higher up than usual, it 
must be there firmly confined by a ligature, being passed 
through the mysentery in the manner already directed. 
If stools pass the ligature and the patient goes on well, 
the ligatures may remain until they are thrown off by 
ulceration ; but if there are no stools, and the patient 
suffers from a distended abdomen, three of the stitches 
should be cut away, leaving that which attaches the in* 
testine to the hernial sac, as well as that which joins its 
edges at the mysentery. The faeces can then readily 
escape at the external wound ; and as granulations arise 
and the wound heals, the mouths of the divided intes- 
tine will become united, so that the faeces will take their 
natural course." (Cooper.) 

The proposal of Mr. Ramdohr to put the upper ex- 
tremity of the intestine into the lower, and to confine it 
there by a ligature, is objected to by Mr. Cooper, who 
found it impossible to effect it in brutes, and infers its 
impracticability in the human subject. 

When a slough forms on one side of the intestine, so 
as to destroy half the cylinder, the wound generally 
heals, so as to form an artificial anus. When the intes- 

* The mariner in which the ligature is prevented from escaping into the 
cavity of the abdomen, has been briefly noticed in the chapter on wounds of 
the abdomen, in vol. i. 



ELEMENTS OF SURGERY. 83 

tine heals in such a case, its cavity is not sufficient to 
transmit the faeces, and abscesses form, by which they 
are discharged. If the wound in the integuments is 
small, and the intestine has more than half its cylinder, 
it would be naturally supposed easy to unite it ; and cases 
of success are related, but in the instances in which Mr. 
Cooper knew it attempted, it has not been attended with 
success. 

i( As it appears, therefore, that there is little proba- 
bility of relief to the patient when this state is once es- 
tablished, the surgeon should attempt, by all the means 
in his power, to prevent its occurrence. 

" The means which will occur to the mind as being 
most likely to effect this object, will probably be to make 
an uninterrupted suture upon the opening in the intes- 
tine ; but this treatment would leave the intestine with 
only half its cylinder, the faeces will not pass, they will 
either soon burst the stitches from the wound, or it will 
become necessary for the surgeon to cut them to unload 
the intestine, and prevent the death of his patient. 

"There is a curious difference in the facility with 
which a longitudinal and transverse wound of the intes- 
tine unite. It has been already shown, that the trans- 
verse heal readily ; but with respect to the longitudinal, 
they have a contrary tendency. 7 ' 

From some experiments performed in this city by Dr. 
T. Smith of St. Croix, it appears that the intestines of 
dogs readily recover from extensive longitudinal wounds, 
though more attention to prevent the escape of their con- 
tents is necessary. 

In every case where the intestinal canal is partially 
destroyed by mortification it is best to cut out the whole 
cylinder at the mortified part, and not to attempt to treat 
it as a longitudinal wound by cutting out only the portion 
actually gangrenous. 

After the operation for hernia, it is necessary to close 



§4 ELEMENTS OF SURGERY. 

the edges of the wound by adhesive plaster, or if neces- 
sary from its extent or from a difficulty of retaining them 
without it, by an interrupted suture. The patient should 
remain at rest on his back during the cure, avoiding all 
efforts of the abdominal muscles, and every thing likely 
to occasion peritoneal inflammation. In general, the 
bowels evacuate themselves within a few hours after the 
operation ; if not, a mild injection may be given. 

In very large hernise, especially in those where there 
is reason to expect adhesions of the sac and its contents, 
Mr. Cooper advises simply to dilate the stricture without 
exposing the cavity of the sac. 

Hernial are sometimes strangulated when they are so 
small as not to protrude externally at the abdominal 
ring, the stricture being situated at the inner opening of 
the inguinal canal i. e. " the aperture at which the sper- 
matic cord first quits the abdomen." This is not easily 
detected, and has been found on dissection, in cases 
where no such thing has been suspected. A fulness is 
generally to be felt just above the abdominal ring, and 
when strangulation takes place great pain and soreness 
are perceived at the part. 

Mr. Cooper directs in these cases the operation to be 
performed in the following manner. u The incision is 
to be begun over the tumour half way between the symphy- 
sis pubis and the spinous process of the ilium, and extend- 
ed downwards parallel to Poupart's ligament, as low as 
the abdominal ring. This incision, which only divides the 
integuments, exposes the tendon of the external oblique 
muscle, which being next cut through in the same direc- 
tion, without cutting the abdominal ring, the hernial sac 
comes in view, extending from the abdominal ring to the 
opening at which the spermatic cord quits the abdomen. 
The sac is then to be opened to the manner described in 
a former chapter, and the intestine examined. A probe- 



ELEMENTS OF SURGERY. 85 

pointed bistoury being then introduced behind the stric- 
ture which is formed by the tendon of the transversalis, 
this is to be divided in an upward direction. In this 
case, however, it is of little consequence whether the 
stricture be divided straight upwards, or outwards, or 
outwards and upwards towards the ilium ; as the epi- 
gastric artery is in this variety of hernia on the inner 
side of the hernial sac. But for the same reason a di- 
rection of the incision inwards or towards the pubis, must 
always be carefully avoided : and to prevent any doubt at 
the time of the operation, the incision upward at the 
middle of the mouth of the sac will be the most proper. 

ft After this operation, as this part of the abdominal 
parietes is weakened by the divisiou of the tendon, a 
truss must be put on as soon as possible. 

ft It has been proposed to return into the abdomen the 
hernial sac, without opening it. For this purpose the 
stricture is first to be divided, the intestine and omentum 
returned from it if possible, and the sac is then to be 
pushed into the cavity of the abdomen. 

" In a very small hernia this operation is practicable, 
because the sac has then contracted no strong adhesion 
to the surrounding parts, and it can be also readily done 
in the female ; but if the hernia is comparatively large, it 
cannot be effected without much dissection, which in in- 
guinal hernia in the male could not always be safely per- 
formed, on account of the frequent varieties in the course 
of the spermatic cord, the vessels of which in large her- 
nial are always more or less turned from their. usual 
course. 

" As there would be often much difficulty in executing 
this part of the operation, it will be best to push back 
the contents only, without attempting to return the sac, 
as the patient is equally liable to a future protrusion, al- 
though the sac is returned." 

Mr. Cooper has related several cases of inguinal her- 



g 6 ELEMENTS OF SURGERY. 

nia ill which the hernia was situated at the inner side of 
the epigastric artery. * The abdominal ring is closed 
towards the abdomen by the tendons of the internal ob- 
lique and transversalis muscles, the lower part of these 
tendons are inserted into the pubis, and connected with 
the fascia, which passes upwards from the external ob- 
lique muscle at Poupart's ligament ; if this tendon is un- 
naturally weak, or if from mal-formation it does not exist 
at all, or from violence has been broken, a protrusion of 
the viscera may then take place immediately behind the 

ring. 

« Below the abdominal ring the appearance of this tu- 
mour differs from that of common bubonocele in being 
near the penis ; and the spermatic cord passes on its out- 
er side instead of its posterior part, particularly at and 
above the abdominal ring. 

" Above the abdominal ring the sac passes directly 
upwards, so that no part of it takes the usual oblique di- 
rection towards the anterior superior process of the ilium, 
but rather the contrary direction inwards towards the 
navel. Examined by accurate dissection its course is as 
follows : — The sac first protrudes between the fibres of 
the tendons of the transversalis, nearly an inch directly 
above the ring. It then passes under the fibres of the 
tendon of the internal oblique muscle. The epigastric 
artery runs upon the outer side of the hernial sac. The 
spermatic cord has no connexion with it above the ring. 
The hernia then emerges from the abdominal ring, the 
spermatic cord being on its outer side, and it is covered 
with the fascia given off by the tendon of the external 
oblique, but not by the cremaster muscle," 

This species of hernia when reducible should be treat- 
ed in the usual way, " the truss should be longer than 
that required for common hernia, because the hole through 
which the sac emerges from the abdomen is an inch and 



ELEMENTS OF SURGERY. 87 

a half further inwards towards the pubis ; so that the 
pad of the truss must reach round as far as the abdomi- 
nal ring itseTf, but still is not to rest upon the pubis. In 
other respects the form of the truss does not require to 
be changed. 

" If irreducible, the same means must be employed as 
in the common species of inguinal hernia. 

" When strangulated, the attempt at reduction should 
be directed differently from the usual mode. The tumour 
is, as before, to be grasped with one hand, but the fin- 
gers of the other are to be placed at the abdominal ring 
to knead the hernia at that part, directing the pressure 
upwards aud outwards, to return the tumour into the ab- 
domen. 

" If the operation for this variety of hernia be perform- 
ed in the manner usually advised in bubonocele, that is 
by dilating the hernial sac and stricture upwards and 
outwards, the epigastric artery will certainly be divided. 
It has therefore been recommended to alter the direc- 
tion of the dilating incision to upwards and inwards, to 
avoid the epigastric artery ; and, if the surgeon is certain 
as to the species of hernia, that is the safest plan. But 
if, in some instances, the operator is directed to make/ 
the incision in one way, and in others precisely the re- 
verse, there will always be reason to fear some mistake 
in practice, which would be attended with the most seri- 
ous consequences ; such mistakes, it is true, would hard- 
ly occur to a surgeon constantly in the habit of dissection, 
but to the greater number, the distinguishing marks of 
the two species will not be sufficiently discriminative. It 
is therefore desirable to point out such a mode of operat- 
ing as would ensure the safety of the patient, whatever 
kind of hernia was found. Such are the advantages 
possessed by the method of making the division directly 
upwards, opposite to the middle of the hernial sac, for 
in this direction the epigastric artery is certainly avoided. 



88 ELEMENTS OF SURGERY. 

" The operation, therefore, is to be performed in the 
following manner : — The surgeon first makes an incision 
through the integuments, along the middle of the tumour, 
from its upper to its lower part, following the longitudi- 
nal direction of the tumour ; so that if it has any inclina- 
tion inwards towards the navel, the incision is to incline 
the same way. The fascia being thus exposed, is divi- 
ded over the surface of the tumour from the abdominal 
ring, down to its lower extremity. The hernial sac, 
which now comes in view, is then opened, from an inch 
below the ring down to the lower part of the sac, in the 
same cautious manner as has been formerly described. 
The surgeon tjien passes his finger into the sac and feels 
for the stricture ; if at the abdominal ring, he introduces 
the blunt-pointed bistoury between the sac and the ring, 
slitting the latter directly upwards, till the aperture is 
large enough to allow of the return of the parts ; if the 
stricture is above the ring, he follows it with the knife 
still in the same direction, and anterior to it, opposite the 
middle of the mouth of the sac, till the dilatation is suffi- 
cient to allow his finger to slip into the cavity of the abdo- 
men ; after which the hernia is to be pushed up, or, if 
anot in a fit state for that purpose, to be treated as men- 
tioned in a former chapter. The parts anterior to the 
sac above the ring, and divided by the knife, are the 
tendons of the transversalis and internal oblique muscles. 
If the stricture is within the sac, still the same direction 
is to be preserved, but the knife must then be passed 
into the sac itself. 

" In this way the epigastric artery will, with certainty, 
be avoided ; which it cannot be if the division of the 
stricture is made outwards, and in the common hernia 
it will be divided by dilating inwards." (Cooper.) 

Inguinal hernia is much less frequent in women than 
in men. It is not so liable to be mistaken for other dis- 
eases in the female as in the male. The treatment is 



ELEMENTS OF SURGERY. 89 

nearly the same ; when reducible a truss is to be worn 5 
if irreducible it should be supported by a T bandage 
passing over it. It never acquires a large size. When 
strangulated the usual remedies are to be employed, and 
if these be unsuccessful the operation is to be performed. 
The first incision should extend from the abdominal ring 
to the lower extremity of the tumour which is not far be- 
low it : the stricture is to be dilated if the contents of 
the sac are judged to be in a state proper for reduction ; 
and if this be doubtful, the sac is to be opened, and the 
viscera contained in it examined and treated as under 
similar circumstances in the male. 

Inguinal hernia in women, as in men, is sometimes so 
small as not to appear externally, the parts not having 
forced their wgiy through the abdominal ring. When the 
disease is discovered, it is to be treated in the usual man- 
ner ; and if an operation become necessary an incision 
must be made, and the tendon of the external oblique 
muscle exposed ; this is next to be cut through, and the 
hernial sac will be brought into view. If the protruded 
viscera cannot now be returned, the sac must be opened, 
and if necessary the stricture which will be found at the 
internal orifice of the inguinal canal must be divided. 



Vol. II. N 



90 ELEMENTS OF SURGERY. 



CHAPTER XI. 



Artificial Anus. 



When in consequence of mortification the intestinal 
tube is partially or completely destroyed, and unites to 
the wound in the parietes of the abdomen, an unnatural 
or artificial anus is produced through which the faeces 
are evacuated. If this aperture be high up in the in- 
testine death is said to result from inanition, in conse- 
quence of the deficiency of absorbents to take up nou- 
rishment for the body. The intestine contracts conside- 
rably below the aperture, and no faeces are voided by the 
anus, although some mucous evacuations are occasional- 
ly discharged. 

Such a condition is truly deplorable, and every effort 
should be made to avoid the evil by effecting the restora- 
tion of the parts, previously to mortification, but where 
the intestine is found mortified, surgical aid is very often 
unavailing, and the artificial anus is the only event by 
which life can be preserved. 

The involuntary discharge of wind and faeces from the 
artificial anus, is a great inconvenience, and compresses 
have been applied with a view to prevent it, but the most 
common apparatus is a receptacle of leather or horn fas- 
tened over the part by means of a band passed round the 
body. Various machines have been constructed for the 
purpose, but the more simple are to be preferred for a 
very obvious reason — they are the most cleanly. What- 
ever apparatus may be used however, should be so con- 
structed as to make pressure upon the part, in order to 



ELEMENTS OF SURGERY. 91 

prevent a prolapsus or eversion of the intestine, which is 
otherwise apt to occur. 

When this prolapsus takes place, a tumour of consi- 
derable size forms, and sometimes the prolapsed intes- 
tine inflames and swells, obstructing the evacuation of 
the faeces. In general it can be readily replaced and 
occasions no permanent inconvenience, but it is best to 
guard against a return of it, by means of a compress of 
lint bound firmly upon the part, a plan which Desault 
recommends in preference to all others ; when, however, 
the reduction cannot be effected by the hand, it must be 
attempted by gradual and long continued pressure upon 
the prolapsed parts. 

In order to prevent the inconveniences attending such 
cases, Mr. Cooper recommends a square cushion covered 
with oil silk which is to be placed over the artificial 
anus, and a steel truss which exerts but a slight degree 
of pressure being placed upon it confines the fasces so as 
to lessen the offensive smell, and allows the patient to 
seek a convenient situation for an evacuation. This 
plan answers extremely well if the faeculent matter has 
some consistence, but if the aperture is in the ileum, the 
contents of this intestine are with difficulty confined. 
These remedies only palliate the disease, in order to ef- 
fect a radical cure, other measures become necessary. 

Desault accomplished the radical cure of artificial 
anus in several instances. The means which succeeded 
in his hands were the application of compresses or plugs 
of lint, introduced into both portions of the intestine, 
which by pressing down the angle formed by their junc- 
tion, make a direct passage for the faeces and dilate the 
canal at the injured part. When this is done air and faeces 
are found to pass sometimes through the natural pas- 
sage, after which the external aperture gradually closes. 
Laxative medicines are to be occasionally administered 
during the treatment. Unhappily, however, the plan 



92 ELEMENTS OF SURGERY. 

found successful in a few cases by Desault, has not suc- 
ceeded equally with other surgeons, and it evidently 
cannot be employed where the angle of junction between 
the two ends of intestine is very acute. 

In a patient with artificial anus at the Pennsylvania 
Hospital Dr. Physick performed an operation, which will 
probably be found to afford complete relief in many si- 
milar cases. The sides of the intestine in this instance, 
were consolidated laterally, or in Mr. Cooper's lan- 
guage, like a double-barrelled gun. In order to ensure 
this union a ligature was passed through the intestine 
and suffered to remain a week, keeping its sides in close 
contact, after which Dr. Physick cut a hole in the side 
of the intestine where the two portions had thus united, 
and by stopping the external orifice, the faeces regained 
their natural route, the external aperture was afterwards 
healed, and the patient relieved from his most loathsome 
complaint; he has for several years enjoyed perfect 
health. 



ELEMENTS OF SURGERY. 98 



CHAPTER XII. 



Of Femoral Hernia. 

Hernia is denominated femoral or crural, when the 
protrusion takes place under the crural arch.* 

It is entirely impossible to understand this subject 
without a knowledge of the anatomy of the parts concern- 
ed, to the investigation of which much attention has of 
late been paid by several eminent anatomists and sur- 
geons. The present Dr. Monro, availing himself of the 
labours of Albinus, Gimbernat, and Hey, has published 
in his essay on crural hernia, and still more recently in 
his morbid anatomy, some very important observations 
on this subject. In addition to his works, the reader is 
particularly referred to Mr. Astly Cooper's matchless 
treatise on this subject, and to the valuable essay of Mr. 
Lawrence in which a few corrections of Mr. Cooper's 
plates are contained. The necessary dissections being per- 
formed in addition to the study of these authors, the stu- 
dent will be prepared to understand the nature and treat- 
ment of crural or femoral hernia ; but I cannot forbear to 
repeat the necessity of dissections, for it is certain that no 
correct ideas can be otherwise obtained. Indeed the 
best anatomical descriptions, appear sometimes confused 
and unintelligible, to those who have never made use of 
the knife in their investigations. 

Femoral hernia occurs more frequently in women than 
in men, and in general commences with a pain on straigh- 

* Crural arch is a synonyme for Poupart's ligament, which is formed by the 
lower edge of the tendon of the external oblique muscle, extending from the 
anterior superior spinou* process of the os ilium to the os pubis, 



94 ELEMENTS OF SURGERY. 

tening the thigh, which extends to the stomach and pro- 
duces nausea, which subsides when the thigh is flexed 
upon the pelvis. 

" The first distinct external mark of crural hernia is a 
general swelling of the part easily returnable by pres- 
sure, descending in the erect, and ascending in the re- 
cumbent posture, and which at first seems to be only the 
dilatation of the sheath that contains the crural artery 
and vein. The next appearance is that of a small cir- 
cumscribed tumour, about the size of the finger's end, si- 
tuated under the crural arch, about an inch on the out- 
side of the tuberosity of the pubis, and lying in the hol- 
low between this process and the crural artery and vein. 
As the tumour enlarges, instead of falling downwards 
like the inguinal hernia, it passes forwards and often 
turns over the anterior edge of the crural arch, this being 
the direction in which there is the least resistance. As 
it proceeds, the swelling increases more laterally than 
upwards or downwards, so as to assume an oblong shape, 
the longest diameter being in a transverse or horizontal 
direction. In the female it is generally very moveable, 
and being soft, and the skin not being discoloured, it has 
the appearance merely of an inguinal tumour of the 
absorbent glands, but in the male the skin is generally 
not so loose, the swelling not so distinctly circumscribed, 
and the tumour appears buried more in the substance of 
the thigh." (Cooper.) 

This species of hernia seldom acquires a large size ; 
Mr. Cooper, however, has seen it in two cases very 
large, occupying the whole of the hollow from the an- 
terior superior spinous process of the ilium to the pu- 
bis ; and he quotes a case from Mr. Thompson of Edin- 
burgh, in which the tumour extended half way down the 
thigh. In this case, the parietes of the abdomen were 
so thin that the peristaltic motion of the intestines could 
be distinctly perceived. The crural hernia is, how* 



ELEMENTS OF SURGERY. 95 

ever, smaller than the inguinal, and therefore more dan- 
gerous. 

" The direction in which the crural hernia passes, is 
obliquely inwards and forwards, and, excepting at first, 
very little downwards, so that in cutting into this tumour 
the incision is made in its fundus. This is the general 
situation of the tumour ; but it sometimes happens, that 
instead of crossing the thigh in the direction of the crural 
arch, it extends downwards along the edge of the crural 
vein and the vena saphaena major. 

" The crural hernia, when dissected, presents the fol- 
lowing appearances : when the skin is removed, the su- 
perficial fascia of the external oblique muscle is laid 
bare, which, though it is of a delicate texture in its com- 
mon state, when pressed upon by a hernia becomes ex- 
tremely thickened and very distinct, more especially in 
a subject loaded with fat. Under this covering there is 
generally another fascia, precisely of the form of the 
hernia itself, and which it very closely embraces. A thin 
fascia naturally covers the opening through which the 
hernia passes and descends on the posterior part of the 
pubis. When the hernia therefore enters the sheath it 
pushes this fascia before it, so that the sac may be per- 
fectly drawn from its inner side, and the fascia which 
covers it left distinct. The fascia which forms the cru- 
ral sheath, and in which are placed the hole or holes for 
(he absorbent vessels, is also protruded forwards, and is 
united with the other, so that the two become thus con- 
solidated into one. If a large hernia is examined, this 
fascia is only found to proceed upwards as far as the 
edge of the orifice on the inner side of the crural sheath 
by which the hernia descends, but in a small hernia it 
passes into the abdomen as far as the peritoneum and 
forms a pouch, from which the hernial sac may be with- 
drawn, leaving this forming a complete bag over the her- 
nia. In a email hernia the fascia is thicker than the sac 



96 ELEMENTS OF SURGERY. 

itself, but by being gradually extended it becomes thin- 
ner and less distinct. 

« It may be termed the fascia propria of the crural 
hernia, when this fascia is divided, a quantity of adipose 
membrane is found between it and the sac, and when 
this is cut through, the peritoneal sac itself is exposed. 
Behind the hernial sac is the fascia lata, and the sac 
rests in the hollow between that part of it which covers 
the crural vessels, and that which passes over the pec- 
tineus and triceps muscles so that the fascia lata is si- 
tuated posteriorly to the hernia." 

The sac in crural hernia is pyriform, resembling in 
shape the small bottles of elastic gum. 

" The orifice of the sac is surrounded by a fascia or 
cellular membrane, much condensed by an adhesive pro- 
cess which forms with the fascia below a complete bag, 
out of which the hernia may be drawn and the bag left 
behind perfect. Between the orifice of the hernial sac 
and the tuberosity of the pubis is situated the insertion 
of the external oblique muscle into the linea ileo-pecti- 
nea, and ligament of the pubis. Behind it, is the pubis 
covered by its ligament and fascia iliaca ; anterior to it, 
is the beginning of the posterior edge of the crural arch, 
and below this the lunated edge of the fascia lata and 
part of the crural sheath ; and on its outer side is a thin 
process of fascia, which passes between it and the iliac 
vein. Indeed, it is according to the size of the hernia 
that there is more or less remaining of the original fascia, 
which extends from the insertion of the external oblique, 
to the iliac vein. If the hernia is small, a process of this 
fascia remains round the orifice of the sac ; but if it is 
large, the orifice of the sac occupies the whole space be- 
tween the insertion of the external oblique and crural 
vein ; excepting that a thin portion of fascia still remains 
between the vein and the sac. This vein runs on the 
outer side of the hernial sac, about half an inch from the 



ELEMENTS OF SURGERY. 97 

centre of its orifice, and half an inch beyond the vein ; 
and exterior to it is the centre of the external iliac arte- 
ry ; the epigastric artery arises from the external iliac, 
about three quarters of an inch from the centre of the 
sac, and as it passes forwards and upwards it approaches 
this point about a quarter of an inch nearer. The gene- 
ral distances of the different parts are as follows. 

MALE. 

INCHES. 

" From the symphysis pubis to the centre of the 

orifice of the sac. - - - - 2 
the centre of the orifice of the sac to the 

external iliac artery. 1 

the centre of the orifice of the sac to the 

centre of the external iliac vein. - 0| 
the centre of the orifice of the sac to the 

origin of the epigastric artery. - - 0| 
the centre of the orifice of the sac to the 

inner edge of the internal abdominal ring. 1 
the tuberosity of the pubis to the centre 

of the orifice of the crural hernia. - 1 

FEMALE. 

" Each measure is from one-eighth to one-fourth of an 
inch more where the pelvis is large and well formed. 

" The spermatic cord of the male, and the round liga- 
ment of the uterus of the female, pass about half an inch 
anterior to the mouth of the hernial sac, being first si- 
tuated to the outer side, and afterwards crossing its fore 
part. 

" When the opening through which the hernial sac 

has passed is examined anteriorly, it will be found that 

the sac, after descending a little way into the crural 

sheath, turns inward and protrudes the inner part of this 

Vol. II 



98 ELEMENTS OF SURGERY. 

sheath where the absorbent vessels pass. The hernial 
sac is here placed between two columns of fascia of the 
crural sheath ; the one proceeds from the anterior part of 
the insertion of the external oblique muscle into the pu- 
bis, is reflected upon the crural vein, and passes over 
the neck of the sac : the other attached to the point of 
insertion of the external oblique into the linea ileo-pec- 
tinea and ligament of the pubis, is continued behind the 
neck of the sac, and is at last undistinguishably blended 
both with the fascia that covers the crural vein, and with 
that part of the fascia lata which passes over the pecti- 
neus muscle. 

" The same general symptoms characterize crural as 
inguinal hernia ; it appears in the erect, and disappears 
in the recumbent posture ; it dilates when the patient 
coughs, is elastic and uniform to the touch when it con- 
tains intestine, and then gives a guggling noise when it 
returns into the abdomen. When it contains omentum 
the surface is less equal, it feels doughy, and gives no 
particular sound when it returns into the abdomen. 

" The crural hernia is less liable to be confounded 
with other diseases than the inguinal, because tumours 
of the groin from other causes, are much less frequent 
than those of the scrotum, but still great care is required 
to prevent the practitioner from mistaking the disease, 
and persons have to my knowledge, lost their lives from 
such errors, or from the swelling being altogether over- 
looked." (Cooper.) 

Crural hernia bears some resemblance, however, to 
some complaints from which it is important to distin- 
guish it. 

The glands of the groin are sometimes enlarged 
in the situation where femoral hernia is generally situa- 
ted, and such glands have been mistaken for this spe- 
cies of rupture ; there can seldom, however, be any diffi- 
culty in discriminating them unless both complaints exist 



ELEMENTS OF SUUGEUV. 99 

in the same groin, and then if strangulation take place 
the difficulty ceases, and if not, it is of no importance. 

Psoas abscess has some of the appearances of femoral 
hernia, the matter passing down the thigh in an erect 
posture and returning into the abdomen when the pa- 
tient lies down ; coughing and other efforts of the abdo- 
minal muscles produce an enlargement of the tumour in 
both cases. In general, however, the symptoms which 
precede psoas abscess sufficiently indicate its existence, 
and the fluctuation of the pus is easily felt ; pressure on 
the abdomen occasions a tension in the tumour which 
cannot be produced in hernia. The tumour is also in 
psoas abscess, generally nearer the spine of the ilium 
than in hernia, and is larger ; it is unattended with any 
interruption to the alvine evacuations. 

Inguinal and femoral hernia are often mistaken the 
one for the other, they may be distinguished by the fol- 
lowing marks. In inguinal hernia the neck of the her- 
nia may generally be distinguished at the abdominal 
ring, considerably above the os pubis, whereas in femo- 
ral hernia, it is lower, and more towards the outer side. 
The crural arch in femoral hernia may be traced in its 
course from the pubis to the ilium, passing above the 
hernial tumour ; in inguinal hernia it cannot be felt, as 
the tumour is situated above it. 

Crural hernia is said to occur most frequently on the 
right side ; it certainly occurs oftenest in the female sex, 
and in those women who have borne children, oftener 
than in others. 

A portion of intestine most frequently forms the con- 
tents of the sac in femoral hernia, but occasionally the 
omentum is also found, and sometimes the case is an 
entero-epiplocele. The ovaria have been found contain- 
ed in the sac of femoral hernia, and Mr. Cooper has 
given a plate of a case in which the uterus was drawn 
to the orifice of the hernial sac. 

This hernia seldom occurs in early life. 



100 ELEMENTS OP SURGERY. 

Crural hernia is a more dangerous complaint than In- 
guinal ; it is smaller and therefore oftener attended with 
obsruction of the bowels ; it returns with less facility 
into the abdomen, because the opening by which it pass- 
es is narrower and for the same reason it is more apt 
to be strangulated. 

The reduction of a strangulated crural hernia is less 
easy than that of an inguinal, and some difference is to 
be observed in the manner of applying the taxis to effect 
it, Mr. Cooper directs it to be done in the following 
manner. 

" The position of the patient is to be such as to relax 
the abdomen as much as possible, for which purpose the 
shoulders should be elevated, and the thighs bent at 
right angles M'ith the body ; but even this posture pro- 
duces but little effect, unless the knees at the same time 
are brought together. If the parts are dissected directly 
with the view of observing what difference is made in 
the relative tension of parts in the dead body, it will be 
found that when the thighs are extended, the crural arch 
and all its fasciae are upon the stretch ; when the thighs 
are bent, but the knees turned outwards, the fasciae are 
somewhat relaxed ; but when the thighs are bent and 
the knees brought together, the crural arch and its fascia 
are all extremely loosened, and still more are the parts 
loosened by throwing one thigh, when bent, across the 
middle of the other. When the body is in the recum- 
bent posture, the thighs bent, and the knees thrown 
inwards, the surgeon is to place himself over the 
body of the patient, and putting both his thumbs on 
the surface of the tumour, he is to press gently di- 
rectly downwards, as if he were endeavouring to press 
the tumour into the thigh rather than towards the abdo- 
men. If this pressure is steadily kept up for some mi- 
nutes till the surface of the tumour is brought even with 
the line of the crural arch, the hernia may then be press- 
ed towards the abdomen and will return into that cavity. 



ELEMENTS OF SURGERY. 10i 

» am convinced that much of the difficulty found in re- 
turning this species of hernia often depends on the im- 
proper direction given to the pressure ; for if the tumour 
is pressed at first towards the abdomen, it turns over the 
crural arch instead of turning under it, and then the ut- 
most degree of force which may be applied will endan- 
ger the bursting of the intestine, but cannot contribute to 
its reduction." 

In order to keep the parts from descending a spring 
truss must be used, similar to that recommended for in- 
guinal hernia, except that the pad must be constructed 
so as to act lower down. (See Plate 1.) It seldom pro- 
duces a permanent cure and therefore should be worn 
constantly. 

Crural hernia is sometimes irreducible from adhesions 
of its contents', or from the contained parts becoming too 
large to pass back into the abdomen. 

When strangulated the symptoms are the same as in 
cases of inguinal hernia ; the seat of the strangulation ac- 
cording to Mr. Cooper, may be in three different places ; 
first, in the crural sheath, and semilunar, or lunated edge 
of the fascia lata ; secondly, at the posterior edge of the 
crural arch ; or thirdly, in the mouth of the hernial sac 
and fascia which covers it. 

« With respect to the first of these, it will be found 
that a portion of the crural sheath remains below the cru- 
ral arch, which forms a strong circular band by which 
the hernial sac is surrounded. When the sac is drawn 
from the sheath in the male, the orifice by which it has 
passed will be found to be formed by two strong co- 
lumns of fascia, one passing above, and the other below 
the sac, and meeting on the inner side at the posterior 
insertion of the external oblique muscle into the ligament 
of the pubis, and on the outer side at that part of the 
sheath which covers the crural vein. In the female these 
columns are not equally strong, still a portion of the 



102 ELEMENTS OF SURGERY. 

sheath surrounds the hernial sac. If the hernia is large, 
it reaches to the semilunar edge of the fascia lata, and 
is compressed by it. 

" The second place at which the stricture is found, 
and which requires division in large crural herniae, is 
the posterior edge of the external oblique muscle and 
the fascia transversalis, which pass before the mouth of 
the hernial sac, and which extending inwards to be in- 
serted into the pubis, forms also the inner boundary of 
the sac at this part, whilst a small process of fascia on 
the inner side of the vein forms its outer boundary. Thus 
then there are two seats of stricture, one the edge of the 
aperture in the crural sheath, and the other about half 
an inch above it, formed by the posterior edge of the ex- 
ternal oblique muscle. 

" The mouth of the hernial sac is the other seat of the 
stricture^ 

"This aperture is very generally small when compared 
with the size of the hernial sac, and being much press- 
ed upon by the posterior edge of the crural arch it un- 
dergoes a slow process of inflammation, which thickens 
very much the fascia in which it is enclosed. If the sac 
is removed with the fascia which encloses it, its mouth 
will be found to form a dense and compact substance, 
which firmly resists any attempts to dilate it by pres- 
sure. 

" The anterior edge of the crural arch, or Poupart's 
ligament, does not form the stricture, or require any di- 
vision, excepting in very large hernisa. 

" The possibility of crural hernia being the cause of 
strangulation, renders it even more than in inguinal her- 
nia necessary for a physician, called in on account of 
symptoms of ileus, to inquire whether there is any tu- 
mour in the groin, or the upper part of the thigh, for in 
crural hernia the tumour is smaller and less prominent 



ELEMENTS OF SURGERY. 103 

than in the inguinal, and more liable to be overlooked. 
These tumours are sometimes so small that it is not 
without hesitation that the surgeon determines with re- 
spect to the operation ; for they are, when small gene- 
rally covered with an absorbent gland, and with so much 
difficulty distinguished, that I confess, I have more than 
once began the operation with much doubt about the na- 
ture of the tumour, making it rather the means of deter- 
mining with certainty, than being assured that it was the 
disease which 1 suspected. 

" The treatment which this hernia requires when stran- 
gulated, differs but little from that of inguinal : the mode 
of using the taxis has been already explained. 

OF THE OPERATION FOR THE CRURAL HERNIA. 

"The patient is to be placed upon a table three feet 
six inches in height, the body lying in a horizontal pos- 
ture, but with the shoulders a little elevated ; the legs as 
high as the knees, hanging over the edge of the table ; 
and the thighs a little bent, in order to relax the abdomi- 
nal muscles. The bladder must be emptied and the dis- 
eased side shaved. 

" The incision is to be begun an inch and a half above 
the crural arch, in a line with the middle of the tumour, 
and extended downward to the centre of the tumour be- 
low the arch. A second incision nearly at right angles 
with the other is next made, beginning from the middle 
ef the inner side of the tumour and extending it across to 
the outer side ; so that the form of this double incision 
will be that of the letter T reversed. The advantage 
of this form of the incision is, that it gives an opportu- 
nity both of examining the parts distinctly, and of turn- 
ing them aside to give a view of the orifice by which the 
hernia has descended, and of the parts which form the 
external portion of the stricture. 



^ 



104 ELEMENTS OF SURGERY. 

« For want of this precaution I have known great diffi- 
culties occur in the operation, the incision, when single, 
being to small to give a sufficient view of the parts, and 
the depth at which the hernia is situated not allowing 
the surgeon to have a distinct view of the progress of the 
operation. 

"The longitudinal incision sometimes occasions a 
slight bleeding from the division of the external puden- 
dal artery, and it is better to secure the vessel before any- 
thing further is done. 

" The first incision exposes the superficial fascia, which 
is given off by the external oblique muscle, and which 
covers the anterior part of the hernial sac ; but if the pa- 
tient is thin, and the hernia has not been long formed, 
this fascia escapes observation, as it is then slight and 
delicate, and adheres closely to the inner side of the 
skin. 

" When this fascia is divided, the tumour is so far ex- 
posed that the circumscribed forms of the hernia may be 
distinctly seen, and a person not well acquainted with 
the anatomy of the parts would readily suppose that the 
sac itself was now laid bare. This, however, is not the 
case, for it is still enveloped by a membrane, which is 
the fascia that the hernial sac pushes before it as it pass- 
es through the inner side of the crural sheath. This 
membrane, the fascia propria, is to be next divided lon- 
gitudinally from the neck to the fundus of the sac ; and 
if the subject is fat, and adipose membrane lies between 
it and the sac, from which it may be distinguished by 
seeing the cellular membrane passing from its inner side 
to the surface of the sac. This is in my opinion, the 
most difficult part of the operation, for the fascia propria 
is very liable to be mistaken for the sac itself; so that 
when it is divided, it is supposed that the sac is exposed 
and the intestine laid bare ; following up this idea, the 



ELEMENTS OF SURGERY, 105 

stricture is divided in the outer part of the sac, and the 
intestine, still strangulated, is pushed with the unopened 
sac into the cavity of the abdomen. 

" It must be remembered, however, that in large her- 
nise the fascia propria of the sac is sometimes insepara- 
bly united to the superficial fascia, so that the same inci« 
sion divides both. 

" The hernial sac being exposed is to be next opened ; 
and to divide it with safety, it is best to pinch up a small 
part of it between the finger and thumb, to move the 
thumb upon the finger by which the intestine is distinct- 
ly felt, and may be separated from the inner side of the 
sac ; and then to cut into the sac, by placing the blade 
of the knife horizontally. Into this opening a director 
should be passed, and the sac opened from its fundus to 
the crural sheath. A small quantity of serum usually 
escapes when the sac is opened, which is either trans- 
parent or sanious according to the length of time that the 
strangulation has continued. The intestine, or omentum, 
or both, then become exposed. 

" It often happens, however, that there is no fluid con- 
tained in the sac of femoral hernia, even although no ad- 
hesion exists between the sac and its contents ; a circum- 
stance which probably may be attributed to the small 
size of the sac and its contents, and the very limited se- 
creting surface which it affords, for when there is much 
unadhering intestine, there is always a notable quantity 
of serum. If the strangulation has continued for many 
hours, the intestine is also covered with a coating of coa- 
gulable lymph, but not otherwise. 

" The next part of the operation consists in the divi- 
sion of the stricture ; for this purpose the finger is to be 
pushed gently into the sac, and the omentum and intes- 
tine separated from its anterior part, the probe-pointed 
bistoury which I have recommended, which does not cut 
Vol. II. P 



106 ELEMENTS OF SURGERY. 

near its point, is to be pushed into the crural sheath at 
the anterior part of the sac, and the sheath is to be cut 
as far as the anterior edge of the crural arch, or Pou- 
part's ligament. In a small hernia this division, which 
does not exceed half an inch, will be sufficient for the 
reduction of the parts. 

" But when the sheath has been thus divided, if the 
intestine, when slightly compressed, cannot readily be 
emptied, the finger must be passed at least half an inch 
higher, and then the posterior edge of the crural arch 
and the fascia that covers it will be felt, forming a sharp 
edge, strongly compressing the mouth of the hernial sac. 
To divide this edge the knife must be carried within the 
stricture, and being inclined obliquely inwards and up- 
wards at right angles with the crural arch, a cut may be 
very safely made in that direction sufficient for the pur- 
pose of liberating the intestine from pressure. 

"The two incisions which I have directed being made 
from the interior of the sac, any stricture arising from 
the contraction of the sac itself will be at the same time 
removed, and the protruded parts be thus completely li- 
berated. 

« If the hernia is large and any pressure has been 
made on its contents by the semilunar edge of the fascia 
lata, the first incision will divide that edge. 

"Much danger will arise from any forcible attempt 
to press the intestine into the abdomen after the dilata- 
tion of the opening of the crural sheath ; for if the stric- 
ture is at the second part, viz. at the posterior edge of 
the crural arch, this makes so firm a pressure on the 
parts, that the intestine will rather give way than the 
stricture will yield, and I am induced to believe, that 
this seat of the stricture has not been generally under- 
stood ; yet in several of the cases in which I have ope- 
rated, it has been situated there. Mr. John Pearson also 
informed me that he lately operated upon a crural her- 



ELEMENTS OF SURGERY. 107 

ma, and divided all the parts which he could at first feel 
forming the stricture, but still an impediment existed to 
the return of the protruded parts, and he was obliged to 
divide the stricture much higher up before he could re- 
turn them. 

" Surgeons talk very carelessly upon the subject of 
dividing the stricture ; they say that the finger must be 
put into the sac, and wherever the stricture is felt it 
should be divided. Again, it is said, the stricture is si- 
tuated on the inner side of the sac, and derived from the 
pressure of the insertion of the tendon of the external 
oblique, or what they call Gimbernat's ligament. They 
do not consider that a stricture is a circle produced in 
the same way as if a cord were tied round the protruded 
parts, and that the division might be made at any part 
excepting the posterior, where the bone is placed, if other 
circumstances did not prevent it. The stricture may be 
divided on the inner side of the sac, that is, towards the 
pubis ; but to this there are strong objections to be men- 
tioned hereafter. It cannot be divided directly outwards, 
for there the crural vein must necessarily be injured, and 
if the division is made upwards and outwards, towards 
the spinous process of the ilium, the epigastric artery is 
much endangered. However, this artery is not so liable 
to be cut in the crural hernia as has been imagined ; for 
it does not approach nearer than half an inch from the up- 
per and outer part of the sac, and an incision of half an 
inch is more than is usually required to liberate the pro- 
truded parts in crural hernia. The stricture may be 
safely divided upwards and with slight obliquity in- 
wards. 

H Mr. Hey, whose name should be never mentioned 
but with respect, who is not contented with the mere 
practice of his profession, but who studies to improve it f 
advises that the knife should be introduced on the in* 



J08 ELEMENTS OT SURGERY. 

ner side of the sac, and the division be made directly 
upwards. 

« In the female, if the hernia is large, it will be some- 
times, though very rarely, necessary to cut through the 
anterior edge of the crural arch, or Poupart's ligament, 
and this may be done from the inner side of the hernial 
sac by cutting obliquely inwards and upwards. But in 
a large hernia in the male subject, when the division of 
the crural arch is required, a different operation becomes 
necessary to prevent the spermatic cord from being in- 
jured. When the parts have been laid bare, and are 
found to be too large to be liberated by the division of 
the sheath and posterior edge of the crural arch, an in- 
cision should be made through the tendon of the external 
oblique muscle over the mouth of the hernial sac, about 
a quarter of an inch above the crural arch, which will 
expose the spermatic cord. This being drawn by the 
finger, or by a curved line, and removed from the direc- 
tion of the incision, the surgeon carries his finger into 
the sac with the bistoury upon it, and the anterior edge 
of the crural arch is cut without the smallest risk to the 
spermatic cord. 

" When the stricture has been divided, and the pro- 
truded parts liberated from pressure, the state of the in- 
testine must be examined, and if the circulation returns 
in it, if the dark colour produced by the constriction dis- 
appears or is much diminished, and if on drawing down 
the intestine, the part at which it had been girt by the 
stricture appears uninjured, it may then be returned into 
the cavity of the abdomen. If the intestine is mortified, 
that portion of it is to be cut away, and the ends of the, 
intestine joined ; and I would advise, that instead of 
leaving an opening in the intestine for the escape of the 
feces, after the contents of the intestine have been eva- 
cuated at the wound, four ligatures should be applied, 
so as to shut the bowel in the whole of its circumference.. 



ELEMENTS OF SURGERY. 109 

and my reasons for differing in this respect from the opi- 
nion I gave in my former work are, that I have found in 
one case, that, by leaving a small opening, an artificial 
anus followed, and in another that where the upper part 
of the ilium had been mortified, by the small aper- 
ture that was left, every thing the woman swallowed 
was so speedily discharged at the wound that it afforded 
no sustenance, and she died in four days after the opera- 
tion. The stricture must be very freely dilated when the 
restoration of the canal is attempted, or the fasces will 
not pass through the intestine ; and if after twelve hours 
no fasces have passed by the anus, and the vomiting con- 
tinues one of the stitches must be cut, and the chance of 
sustaining life by an artificial anus must be given. 

" I should still have great fears of returning the intes- 
tine into the abdomen after sewing it, notwithstanding 
the experiments which were made by Mr. Thompson 
and myself, and since confirmed by Mr. Smith, in his 
Inaugural Dissertation, which proved that an intestine 
may be returned into the abdomen after being secured 
by ligatures. But it is to be recollected that in the dis- 
ease before us the intestine is highly inflamed, and that 
ligatures ulcerate so quickly in inflamed parts that there 
would be great danger of the escape of the faeces into 
the cavity of the abdomen ; for in a case in which I left 
the intestine within the sac, after securing it by liga- 
tures, the intestine burst open on the third day and an 
artificial anus was produced. I therefore think it safer 
to carry the intestine to the mouth of the hernial sac and 
there fix it by its mysentery. 

" If the intestine is mortified, it requires great care in 
the operation to prevent the portion within the abdomen 
from being torn from the mortified part, which if the fin- 
ger is forcibly introduced into the sac will undoubtedly 
happen, and the fasces escaping into the abdomen will 
destroy the patient in a few hours. To prevent this, 



410 ELEMENTS OF SURGERY. 

after exposing the intestine, and finding it mortified, the 
finger should not be put into the mouth of the sac, but 
the bistoury only be passed into the stricture ; and when 
this is divided, the intestine is to be gently drawn down 
into the sac to expose the part at which it has been 
girt. 

« If the intestine adheres to the sac, extraordinary 
caution is required, both in the division of the stricture 
and in separating the adhesions. It is best to begin with 
gently separating the adhesions with the finger rather 
than with the knife, which can generally be effected 
without doing violence to the parts ; but if the adhesions 
are short and very firm, portions of the sac must be cut 
away and returned into the abdomen with the intestine 
to which they adhere ; the stricture too must be divided 
fibre by fibre with extraordinary care. 

" Putting a ligature around the whole of the protruded 
omentum is either useless or dangerous : if it is placed 
on the mortified part, it is obvious it must be useless, as 
the sloughing proces3 will go on above it : if it is placed 
upon the healthy part of the omentum, why divide the 
stricture, as another is made immediately by the thread 
which is applied around it. 

" Leaving the omentum in the hernial sac to slough 
appears to me unadvisable because it is unnecessarily 
preserving a discharge for a length of time and protract- 
ing the cure. I have never seen this intentionally done, 
but in a patient in Guy's Hospital ; the omentum which 
had been returned into the abdomen redescended into the 
sac on the sixth day from the operation and gradually 
sloughed, keeping up during the time a very offensive 
discharge, and a great degree of constitutional irrita- 
tion. 

" When the protruded parts have been returned into 
the cavity of the abdomen, sutures are to be made upon 



ELEMENTS OF SURGERY. 11 * 

the integuments, and the wound closed as carefully 
as possible by lint, adhesive plaster, and bandage." 
(Cooper.) 

Varieties in crural hernia are more rare than in most 
other species. Some of the most frequent have been 
noticed by Mr. Cooper ; the only one which I think it 
important to mention is that in which the obturator ar- 
tery passes round the neck of the hernial sac. Of this 
variety which Mr. Cooper never saw he quotes two 
cases ; I have myself seen one. In this case no part of the 
neck of the sac could be felt free from the pulsation of a 
very considerable artery. Dr. Physick very promptly 
divided the stricture by cutting in the usual direction, 
but taking great care to make a very small incision or 
rather scratch with the point of a bistoury, though the 
stricturing tendon. A very small dilatation of the stric- 
ture in these cases is sufficient, and therefore, I think 
the direction in which the incision is made is of less im- 
portance than many surgeons have imagined, as we may 
safely cut directly towards a blood vessel, without risk of 
wounding it provided the surgeon be cautious and dex- 
terous.* As Dr. Phyick's patient happily recovered 
and is now living I am unable to describe particularly 

* For a more minute account of this subject, I refer to Cooper, Law- 
rence, and Monro ; the last writer supposes that in one of twenty cases, this 
variety occurs ; he adds " there is still another variety as to the distribution of 
the epigastric and obturator arteries; these arteries in some cases come off 
from the anterior iliac artery by separate trunks; and the obturator artery 
passes around that part of the crural arch called Gimbernat's ligament, and is 
attached to it by cellular substance. When this happens, the obturator artery, 
by the descent of a portion of the intestine through the crural ring, is pressed 
upon the very part of the crural arch divided by Gimbernat, in his operation 
for crural hernia. 

" I have seen the obturator artery sent off from the external iliac artery, about 
an inch and a half above, and in others, about an inch below the epigastric 
artery ; and in other cases, even on the outer side of the pelvis, from the super- 
ficial femoral artery ; in which case, the artery ascends along the pectineus 
muscle, and enters the pelvis at the crural aperture. The artery in this case 
it placed behind the crural hernia." (Mowno.) 



112 ELEMENTS OF SURGERY. 

the anatomy of the parts, but in one of the cases related 
by Mr. Cooper, from Dr. Barclay it was found that the 
« epigastric and obturator arteries had arisen by a com- 
mon trunk and that they had passed, anterior to the sac 
before they divided ; after which the epigastric artery 
proceeded upwards to the rectus muscle, and the obtura- 
tor artery passed backwards on the inner side and close 
to the neck of the sac to the obturator foramen through 
which it usually passes. The obturator artery indeed 
very frequently deviates from its natural course, and in- 
stead of arising separately from the internal iliac artery, 
it derives its origin from the external iliac in common 
with the epigastric. But in all the cases which I have 
myself dissected where this variety existed with crural 
hernia, the obturator has passed into the pelvis on the 
outer side of the neck of the sac entirely out of the reach 
of any injury by the knife. In twenty one preparations 
of crural hernia I found six had this variety in the ori- 
gin of the obturator artery. When therefore this artery 
passes before to the sac (as in the case observed by Dr. 
Barclay) the arterial trunk common to it and to the epi- 
gastric is of unusual length ; fo^when the trunk is short, 
the obturator passes behind the sac. A hernia thus si- 
tuated is surrounded by blood-vessels, except at its pos- 
terior part, which might seem to render it advisable to 
deviate from the usual mode of operation to prevent this 
blood-vessel from being wounded. This, however, is 
not so liable to happen where the division of the stric- 
ture is made upwards, or a little upwards and inwards ; 
for I suspect it will be found that the greatest distance 
between the artery and the hernial sac is at its anterior 
part. It is impossible to feel this artery before the in- 
troduction of the knife, for the finger cannot be passed 
behind the posterior edge of the crural arch, beyond 
which this artery is placed, until the stricture has been 
divided. The sac therefore is to be carefully divided 



ELEMENTS OF SURGERY. 118 

anteriorly ; but even supposing the artery to be wounded 
in the operation, it may be asked, what other direction 
of the wound would afford greater facility of tying the 
bleeding vessel ? For by slitting up the crural arch, and 
drawing down the mouth of the hernial sac, the vessel 
would be brought into view, and might be secured.'* 
(Cooper.) 

The operation proposed by Gimbernat of cutting in- 
wards, is more difficult than that which has been des- 
cribed, and is attended with more danger of wounding 
the intestine, besides which in some cases the opening 
thus made is not sufficiently large to permit the return 
of the prolapsed parts, and the obturator artery is in 
great danger of being wounded, in which case it could 
not be tied up, whereas if this vessel should be wounded 
in the operation which has been recommended it could 
be very readily secured ; these reasons have induced 
Mr. Cooper and other surgeons to decline the operation. 



Vol. II. Q, 



114 ELEMENTS OF SURGEfiY. 



CHAPTER XIII 



Of Exomphalos or Umbilical Hernia. 



The sac in umbilical hernia passes through a hole at 
the navel by which in the foetus the umbilical vessels 
had been transmitted. This aperture is situated in the 
linea alba, and is never completely filled up with ten- 
don, but with condensed cellular substance and the re- 
mains of the umbilical vein and arteries. 

The peritoneum is perfect behind the umbilicus and 
consequently the umbilical hernia has a sac similar to 
that of the hernias already described. 

" Umbilical hernia begins in the form of a small tu- 
mour, about the size of the tip of the finger, at the navel 
which can be returned by very slight pressure into the 
cavity of the abdomen, but by directing the patient to 
cough, it immediately reappears. As it increases in 
bulk it begins to gravitate, so that the anterior extremity 
of the bend is generally below the level of the umbilical 
opening. If the person is thin, it becomes very pendu- 
lous and distinctly circumscribed, and is then usually of 
a pyriform shape. If nothing is done to check its growth, 
it grows to an enormous size, extending downwards to- 
wards the pubis. The disease in this state produces a 
great deal of suffering, and often endangers life if the 
hernia is intestinal. Almost every thing that is eaten 
too produces flatulency, pain in the protruded part, and 
sickness ; and even slight pressure to return it, gives the 
same uneasy sensations when the intestine is passing 
back through the abdominal opening. If no bandage is 



ELEMENTS OF SURGERY. 115 

habitually worn to confine the hernia, the patient feels 
so much weakness and sinking at the pit of the stomach 
as to be often incapable of any exertion. The bowels 
also are generally irregular, and if the tumour becomes 
inflamed, it swells to a great size, and vomiting and con- 
stipation ensue. These symptoms are much more fre- 
quently happening in this than in the other species of 
hernia, but at the same time they are generally more ea- 
sily removed." 

Umbilical hernia almost uniformly contains both omen- 
tum and intestine. 

" The umbilical hernia is very frequent in the young 
subject, and forms a tumour like the inflated finger of a 
glove, with a slight obliquity downwards. It very gene- 
rally contains intestine, which may be easily returned, 
unless the orifice is very small, in which case the cries 
of the child shew that some pain is given. Irregular 
bowels and costiveness, succeeded by griping and long 
continued purging, are attendant on this disease. 

" A fascia may be distinctly traced over the tumour 
when the hernia is small, but when it becomes of large 
size, the skin, sac, and fascia become so united at the 
anterior part of the swelling, that it is difficult to sepa- 
rate them there, although the fascia may still be dis- 
tinctly observed on the sides of the tumour. 

" There are some varieties in the umbilical hernia 
which require to be mentioned. First, with respect to 
figure, in a thin subject it is generally pyriform, as I 
have already stated, but in fat persons it forms a broad 
and flat swelling, which extends as much upwards as 
downwards. Sometimes in consequence of there being 
a large quantity of fat which separates the skin at a great 
distance from the abdominal muscles, the hernia projects 
as far as the skin of the navel, and then extends up- 
wards and downwards so as to form a tumour which is 



116 ELEMENTS OF SURGERY. 

scarcely apparent upon a superficial examination. But 
when the hernia assumes this extended and flattened 
form in thin persons (which is sometimes the case,) it 
can be embraced by the hand, and its dimensions readily 
ascertained. I have also seen this umbilical hernia di- 
vided into a number of different cells. 

" Besides this variety in the figure of the hernia, there 
is a great difference in the state of the sac. When this 
is small, it is as complete as in other hernise ; but I have 
an example in my possession of the sac having been 
either absorbed or burst, by which openings have been 
formed and portions of omentum protruded through them, 
producing small hernice through the sac of the large one.* 
In this instance two small omental hernice are seen pro- 
truded through the hernial sac, and on the opposite side 
an opening may be observed through which either omen- 
tum or intestine might have passed. 7 ' (Cooper.) 

A curious case of this disease is described by Mr. 
Cooper in which two sacs were found. 

The causes which most frequently occasion umbilical 
hernia are pregnancy, obesity, and ascites in adults, and 
in children, it is occasioned by an unusually large umbi- 
lical cord, and a congenital deficiency of tendon at the 
navel. I have known umbilical hernia suddenly formed 
during parturition, the patient was sensible of something 
giving way at the umbilicus, she was flooding at the time, 
and was delivered of twins ; a tumour formed soon after 
and gradually augmented to a very large size. 

When the reduction of umbilical hernia is to be effect- 
ed by the taxis, the patient should be placed on the back, 
the pelvis and shoulders being slightly raised, and the 
thighs bent forwards. 

The tumour should be pressed backwards, and some- 
what upwards, as the neck of the sac is not in the centre 
of the tumour but above it. 

* An engraving of this may be seen in Mr. Cooper's work 



ELEMENTS OF SURGERY. 117 

When the reduction is effected a truss should be 
worn ; Mr. Hey recommends a new instrument of this 
kind constructed by Mr. Marrison of Leeds, and in 
large umbilical hernia it deserves the preference, but in 
cases where the tumour is small, a circular spring and 
pad constructed like the truss for inguinal hernia, 
answers just as well, and is much more simple. Gra- 
duated compresses, of a conical form, bound round the 
body answer in many cases, where the irritation of the 
steel spring is found inconvenient, which in very corpu- 
lent persons is frequently the case, a great variety of 
bandages and belts are in use for this purpose ; the most 
convenient I have seen used, resembles a pair of 
drawers the compress being fixed to the middle of the 
waistband prevented from descending by a suspensory 
shoulder strap. 

When umbilical hernia becomes strangulated, the 
usual remedies for effecting the reduction are to be em- 
ployed, and if they fail, the stricture must be dilated 
with the knife. I once witnessed a most remarkable re- 
duction of umbilical hernia in a lady, upon whom all the 
usual means of accomplishing this purpose had been 
perseveringly tried for several days without effect. The 
operation was accordingly commenced by Dr. Physick, 
and as soon as the skin over the tumour was divided, 
the lady being greatly terrified, a guggling noise was 
heard in the hernia, and a very slight pressure being 
made it suddenly returned into the abdomen, and noun 
pleasant symptom followed. 

OF THE OPERATION FOR UMBILICAL HERNIA. 

This is generally very simple : the integuments are 
to be divided over the tumour, with great caution not to 
wound the intestine, as there is frequently no sac, or a 



118 ELEMENTS OF SURGERY. 

very thin one, intervening between the skin and the pro- 
truded viscera. The external incision should in small 
herniae extend from the top to the bottom of the tumour, 
but in large hernias this extent of incision is unneces- 
sary ; after which its contents are to be exposed by a 
small incision through the sac, or parietes of the hernia. 
When this opening is made, a small quantity of fluid 
escapes ; a director is now to be introduced and the 
parts divided sufficiently to permit a finger of the sur- 
geon to enter ; with this finger he very readily finds the 
aperture at the umbilicus ; a probe-pointed bistoury* 
is now to be passed along the finger, and the tendon di 
vided upwards sufficiently to permit the protruded parts 
to be returned without much force ; the intestine is to be 
first returned, and afterwards the omentum, unless it be 
necessary to remove it by the knife. The integuments 
are next to be approximated and retained in contact by 
one or two stitches, or if the aperture into the sac be very 
small, by adhesive plaster. 

Mr. Astly Cooper, with a view to diminish the dan- 
ger of peritoneal inflammation, after the operation for 
umbilical hernia, has in two instances performed the 
operation in a different manner, "As the opening into the 
abdomen is placed towards the upper part of the tu- 
mour, he began the incision a little below it, that is, at 
the middle of the swelling, and extended it to its lowest 
part. He then made a second incision at the upper part 
of the first, and at right angles with it, so that the dou- 
ble incision was in the form of the letter T, the top of 
which crossed the middle of the tumour. The integu- 
ments being thus divided, the angles of the incision were 
turned down, which exposed a considerable portion of 
the hernial sac. This being then carefully opened, the 
finger was passed below the intestine to the orifice of the 

* That of Mr. Cooper is to be preferred 



ELEMENTS OF SURGERY. 119" 

sac at the umbilicus, and the probe-pointed bistoury be- 
ing introduced upon it, he directed it into the opening at 
the navel, and divided the linea alba downwards to the 
requisite degree, instead of upwards, as in the former 
operation." When the omentum and intestine are re- 
turned, the portion of integument and sac which is left 
at the upper part undivided, falls over the opening at 
the umbilicus, covers it and unites to its edge, and thus 
lessens the risk of peritoneal inflammation by more readi- 
ly closing the wound. 

The same writer recommends, when the hernia is very 
large, to dilate the stricture without opening the sac at 
all. In such cases he has succeeded by making a small 
incision opposite the neck of the tumour, exposing the 
fascia which covered it, passing a probe-pointed bistoury 
between the fascia and the sac, and dividing the former to 
*he edge of the umbilical ring, then putting his finger to 
the edge of the linea alba, he passed his knife through 
the umbilical hole behind the linea alba, and made a 
small division of it upwards, then withdrawing the knife, 
he pressed upon the tumour and it immediately re- 
turned. 

Mr. Cooper states that " this operation did not take 
more than four minutes in its performance ; it is attended 
with no more danger than the taxis, and if insufficient 
the operation may be afterwards performed in the com- 
mon way by extending the same incision. " 

When strangulation takes place in an old irreducible 
hernia, the stricture should be divided in the manner 
last described, and then the contents of the intestine can 
be readily pressed out of the hernial tumour into the ab- 
domen, and the usual course of the feces is restored ; an 
operation which has been successfully performed by 
Mr. Cooper. 

The colon is more frequently found in umbilical her- 



120 ELEMENTS OF SURGERY. 

nia than any other intestine, and its appendices epiploic^ 
are often enlarged and indurated, — When found in this 
condition it is proper to remove them. 

When the sac contains a very large quantity of omen- 
tum, or when the omentum adheres extensively and has 
become indurated, it is to be removed with the knife, 
care being taken to secure the bleeding vessels by liga- 
tures ; the portion of divided omentum should be left as 
a plug to fill up the orifice of the hernial sac. 

In one case of umbilical hernia, I was greatly em- 
barrassed, by finding the intestine strangulated in several 
different places by bands passing from the omentum to 
the intestine. These bands, which were elongated ad- 
hesions of a very firm texture, converted the hernial sac 
into a cavity resembling the ventricles of the heart; the 
morbid productions extending like the chordae tendineae, 
from one part of the cavity to another ; under several of 
these cords, portions of the ileum had become strangu- 
lated, and by cautious dissection I succeeded in libera- 
ting and returning into the abdomen the recently pro- 
truded parts. 

Umbilical hernia, in very young infants is by no 
means unusual ; Dr. Hamilton declares that for the last 
seventeen years, he has usually seen two cases annually 
of umbilical hernia in new born children. 

When the hernia is small it may be cured by com- 
press bandages ; Mr. Hey succeeded in effecting the ra- 
dical cure of a case of congenital exomphalos in which 
the tumour was as large as a hen's egg, by means of a 
conical compress. Dr. Hamilton has used a mode of 
treatment by no means so safe or simple : after reducing 
the contents of the sac " a ligature was tied firmly round 
its base after which the sac was cautiously opened. It 
proved to be the sheath of the umbilical cord. With two 



ELEMENTS OF SURGERY. 121 

silver pins and some adhesive straps the separated pa- 
rietes abdominis were brought closely together. The 
sac was allowed to drop off, and in a few days the cure 
was complete." 

Umbilical hernia in young subjects according to De- 
sault, occurs more frequently at the age of two or three 
months than at birth. In some rare instances the com- 
plaint which is produced and increased by the cries of 
the infant gradually subsides, but this event is unusual. 

To obtain a radical cure in infancy is of the utmost 
importance, because in the adult it is impossible. By 
keeping the viscera constantly in the abdomen the um- 
bilical ring will gradually contract, and a cure will be 
effected by its obliteration. 

Desault has of late years revived the ancient mode of 
treating this complaint by the application of a ligature, 
and in upwards of fifty cases he found it completely suc- 
cessful. The mode of operating is very simple. The 
child should be laid on its back, the thighs being some- 
what bent, and the head inclined forwards. The sur- 
geon having returned the protruded viscera presses on 
the opening with one hand whilst with the other he 
raises the sides of the sac, and ascertains that no part 
remains unreduced. When this is done a waxed liga- 
ture is to be passed several times round the basis of the 
hernia and secured at eacli turn by a double knot drawn 
tight enough to occasion " an inconsiderable degree of 
pain." The tumour is to be covered with lint, over 
which cemprcsses are to be applied secured by a ban- 
dage and shoulder straps. In a day or two after the 
first ligature is applied, the parts enclosed within it 
shrink, and it becomes necessary to tie a second ligature 
considerably tighter. A third ligature some days after 
often becomes necessary. In eight or ten days the tu- 
mour falls off, and leaves a small ulcer which speedily 
Vol. II. R 



122 ELEMENTS OF SURGERY. 

heals. Although the umbilicus is by this time sufficient- 
ly firm to resist the protrusion of the viscera yet pru- 
dence dictates the propriety of a bandage and compress> 
for several months. The probability of the cure dimi- 
nishes with the age of the patient, and in Desault's 
hands it failed in a girl aged nine years. The opera- 
tion should therefore be recommended and performed 
early. 

This short account of umbilical hernia I shall conclude 
by describing a mode of operating which has been pro- 
posed by Dr. Physick. It consists in making a crucial 
incision through the integuments of the tumour, and dis- 
secting the four angles thus formed down to the neck of 
the sac ; an opening is next to be made into the sac at 
its upper part of a sufficient size to afford a view of its 
contents ; should these be sound they are to be reduced 
if practicable, without dilating the umbilical aperture ; 
but if this cannot be done, that aperture is to be enlarged 
outside of the sac, taking care not to wound the neck of 
the sac. When the contents of the sac are reduced, a li- 
gature is to be tied round its neck. 

The chief advantages proposed by this mode of ope- 
rating are, that a full examination may be made of the 
protruded viscera by a free opening of the sac, and all 
danger of peritoneal inflammation from this opening is 
precluded by the ligature which produces a closure of 
the neck of the sac and prevents the exposure of the ab- 
dominal cavity. Dr. Physick has never had an oppor- 
tunity of trying the plan, but I am happy to state that 
Dr. Wistar has performed it with complete success. 



ELEMENTS OF SURGERW 423 



CHAPTER XIV 



Of Ventral Hernia. 

This resembles the umbilical, except that the protru- 
sion instead of being at the naval is situated in some 
other part of the parietes of the abdomen ; most fre- 
quently in the linea alba, but sometimes in the linea se- 
milunaris. It is a very rare complaint. 

The symptoms of ventral hernia resemble those of the 
umbilical, except that the stomach is sometimes contain- 
ed in the hernial sac when it is situated high up near the 
sternum in consequence of which the tumour is augment- 
ed after eating and the digestive process is greatly inter- 
rupted. 

The disease is produced by natural or preternatural 
apertures in the parietes of the abdomen ; the holes by 
which blood-vessels pass through the tendons are some- 
times unusually large, and a protrusion of the viscera 
takes place. Sometimes there are deficiencies of tendon 
at particular places, and sometimes wounds of the abdo- 
men give rise to ventral hernia, the part injured not being 
properly filled up. 

With respect to the treatment, the remarks made on 
umbilical hernia will suffice, as there is no important 
difference between the two cases. 



124 ELEMENTS OF SURGERY» 



CHAPTER XV. 



Of Hernia Congenita. 

In the male subject, congenital hernia is formed by a 
protrusion through the abdominal ring into the tunica 
vaginalis testis ; it can only happen in those cases where 
this cavity remains continuous with the general cavity of 
the abdomen. The protruded viscera are in contact 
with the testicle, the hernial sac being the tunica vagi- 
nalis. 

This peculiar species of hernia excited the attention 
of many anatomists and surgeons about the middle of 
the last century, among whom Dr. Hunter, Baron Hal- 
ler, and Mr. Pott, have been very conspicuous, and have 
described it very accurately. 

The differences between hernia congenita, and com- 
mon inguinal hernia, are of no great practical impor- 
tance, their symptoms and treatment being nearly si- 
milar. 

Hernia congenita may be distinguished from common 
inguinal hernia, by its existence from the period of in- 
fancy, and by the impossibility of feeling the testicle, 
which in common scrotal hernia is very easily distin- 
guished. 

In applying trusses in very young subjects, the sur- 
geon should attend particularly to two circumstances, 
the replacement of all the protruded parts, and the de- 
scent of the testicle which might be prevented by the 
truss. 

If an operation become necessary for the relief of a 
strangulated congenital hernia, the sac should be divided 



ELEMENTS OF SURGERY. 125 

no lower than the upper end of the testis, a sufficient 
portion being left to cover that organ. 

Mr. Hey, and Mr. Cooper, have each published a cu- 
rious case of congenital hernia, in which the protruded 
viscera contained in a hernial sac passed down into the 
tunica vaginalis testis. In such cases it would be un- 
necessary and improper to open the hernial sac, the 
tunica vaginalis being opened the sac and its contents 
should be reduced together. 

A species of congenital hernia may occur in the fe 
male, the intestine passing in these cases with the round 
ligaments of the uterus through the abdominal ring. Its 
existence could not however be ascertained in the living 
subject, and no peculiar treatment would be required if 
it were known. 

An opening called by Nuck a " diverticulum," exists 
in about one of eight or ten female infants, at the abdo- 
minal ring, and tiiis diverticulum forms the sac of female 
hernia congenita ; the diverticulum is a small process of 
peritoneum, passing over the round ligament of the uterus, 
and terminating in a blind pouch at the groin. 

Having described the circumstances and treatment of 
the most common species of hernia, I refer for those 
which more rarely occur (and their varieties are very 
great) to Mr. Astly Cooper, and to Mr. Lawrence. The 
principal of them are described by the former of these 
writers in his chapters on pudendal, vaginal, peri- 
neal, THYROIDEAL, CYSTIC, ISCHIATIC, PHRENIC, MESEN- 
TERIC and MESocoLic hernije. 



126 ELEMENTS OF SURGERY. 

CHAPTER XVI. 

Of Hydrocele. 

A collection of water within the scrotum, is called 
Hydrocele. The situation of the fluid varies, and ac- 
cordingly systematic writers notice several species of 
hydrocele. 

The first of these is the anasarcous tumour of the 
scrotum, which most frequently occurs as a symptom of 
general dropsy, but in some rare cases is produced in the 
following manner. A hydrocele of the tunica vaginalis 
testis bursts, and the water escaping into the surrounding 
cellular texture, forms the anasarcous tumour, which is 
gradually absorbed, and the aperture healing, the dis- 
ease resumes its original form, the water being confined 
within the tunica vaginalis. 

The anasarcous hydrocele forms a soft tumour of the 
scrotum, affecting equally the cellular texture surround- 
ing each testicle. The skin is not reddened or inflamed, 
but when distended considerably, becomes tense and 
smooth, its rugae entirely disappearing. The testicles 
cannot be felt, they are situated in the middle of the tu- 
mour. When pressed with the finger, it has a doughy 
feel, the indentation remaining some time after the pres- 
sure is removed. The skin of the penis is also similarly 
distended. 

The treatment of this complaint differs in nothing from 
the treatment of general anasarca. The only surgical 
operation required, is when punctures become necessary 
for the evacuation of the water. Large incisions are im- 
proper, and endanger gangrene. Five or six small 



ELEMENTS OF SURGERY. 127 

apertures should be made, by inserting the point of a lan- 
cet just deep enough to pierce the cutis vera, through 
these the water flows freely, and the distention of the 
skin is removed, after which soft dry linen cloths should 
be applied, and renewed occasionally as they become 
wet. 

In addition to the anasarcous hydrocele, Mr. Pott 
describes three other species. 

First, That which consists of a collection of water, 
in the cells of the tunica communis, or cellular mem- 
brane, enveloping and connecting the spermatic vessels. 
Second, That which is formed by the extravasation 
of a fluid, in the same coat as the former, but which, in- 
stead of being diffused through the general cellular struc- 
ture of it, is confined to one cavity or cyst, in which all 
the water constituting this species of disease is contain- 
ed ; the rest of the membrane being in its natural state. 
Third, That which is produced by the accumulation 
of a quantity of water, in the cavity of the tunica vagina- 
lis testis. 

"These three are distinct, local, and truly within the 
province of surgery. They may accidentally be com- 
bined or connected with other disorders, but not neces- 
sarily ; and are frequently found in persons whose gene- 
ral habit is good, and who are perfectly free from all 
other complaints." 

The first species I believe is very rare, and for an ac- 
count of it I refer to Mr. Pott, it is much more common 
to find the water collected in one or more cysts upon the 
spermatic cord. 

Ill the ENCYSTED HYDROCELE OF THE SPERMATIC CORD, 

the testicles can be felt distinctly at the bottom of the 
tumour, there is an evident fluctuation of a fluid within 
the scrotum, and the parts are geuerally diaphanous. 
The swelling extends gradually upward, and in some 
»ases probably extends through the abdominal ring, in 



128 ELEMENTS OF SURGERY. 

which case it resembles hernia, and in one case I have 
known a truss worn for such a tumour, the surgeon hav- 
ing mistaken the disease for bubonocele. In the case 
alluded to Dr. Physick was consulted, and found that, 
although, as in hernia, the tumour could be nearly pres- 
sed up into the abdomen, yet it returned the moment the 
pressure was removed ; the testicle was felt distinctly at 
the bottom of the tumour, which was diaphanous, and 
evident fluctuation could be perceived by pressure upon 
its opposite sides. A puncture was made, and the water 
was evacuated, after which no tumour remained, and of 
course no protrusion of the bowels was connected with 
the hydrocele. 

The treatment of hydrocele in those cases where the 
water is contained in one or more cysts upon the sper- 
matic cord, is to be effected by drawing off the fluid 
with a lancet or trochar ; in young subjects a perma- 
nent cure is often effected in this manner. Should the 
water collect again, it is to be treated by injecting wine 
into the cyst, in the manner practiced for the cure of 
hydrocele of the tunica vaginalis. 

Mr. Pott recommended a free incision through the 
coats of the cyst, a severe and dangerons operation 
which he confesses to have known sometimes followed 
by the death of the patient ; the milder method of in- 
jection is certainly to be preferred. 

The HYDROCELE OF THE TUNICA VAGINALIS TESTIS, 

is that in which the water is collected in the process of 
the peritoneum which invests the testicle. 

The tunica vaginalis, in a natural state, secretes a 
fluid which lubricates its internal surface and that of 
the testicle. An increased secretion, or a diminished 
absorption of this fluid, causes a gradual distention of 
the cavity in which it is contained, and in some cases 
the quantity of fluid augments to a very great size. 



ELEMENTS OF SURGERY. 129 

In some instances the disease forms too suddenly to 
be thus accounted for. Mr. Else declares, that he has 
known a hydrocele to form immediately after a sensation 
in the parts, which the patient ascribed to a rupture of 
something within the scrotum. In such cases the burst- 
ing of a lymphatic vessel probably occasions the disease. 

Mr. Ramsden has rendered it extremely probable, 
that in many instances, hydrocele of the tunica vagina- 
lis is occasioned by the existence of stricture, or local 
irritation in the urethra.* That this is sometimes the 
case, has been taught for several years by Dr. Physick, 
in consequence of his having cured a hydrocele, in a 
citizen of Philadelphia, by bougies. The bougies 
being omitted, the stricture returned, and with it a hy- 
drocele, which was a second time cured in the same 
manner. It is certain however that in very many cases 
of it, no disease of the urethra exists. 

This species of hydrocele occurs at all ages, and is 
sometimes congenital. The tumour generally forms at 
the bottom of the scrotum, near one of the testicles, and 
is commonly confined to one side only ; it is pyriform, 
being larger below than above ; it is soft at first but be- 
comes hard and incompressible ; it is not inflamed or 
changed in colour, and is attended with no pain, the 
principal inconvenience sustained by the patient being 
from the weight and bulk of the parts. The testicle 
can be felt at the posterior and inferior parts of the scro- 
tum, until it becomes large and tense. In general, a 
fluctuation can be perceived, and the tumour is diapha- 
nous. 

A careful attention to these symptoms, and to those 
which characterize other tumours in the scrotum, will 
effectually discriminate between them. 

* Practical Obsei-vations on the Sclerocele, &c. London, 1811, 

Vol. II. S 



i30 ELEMENTS OF SURGERY. 



TREATMENT. 



The administration of internal remedies has no effect 
upon this disease, unless employed in a very early stage. 
The affusion of cold water has been found useful in a 
few cases, especially in young children, in some in- 
stances however the hydrocele of children spontaneously 
Subsides, but the cure is evidently expedited by the cold 
Water. When this remedy is used it should be pour- 
ed out of a tea-pot, four or five times a day over the 
scrotum. 

Severe purging has, in some instances, occasioned a 
speedy cure of hydrocele ; it very rarely however is 
found useful, and a surgical operation becomes necessa- 
ry for the evacuation of the water. The radical cure of 
hydrocele cannot be effected by merely drawing off the 
fluid, as it very speedily collects again. In order to 
prevent this, and finally to cure the patient, it is neces- 
sary to excite an inflammation of the tunica vaginalis, 
and a consequent obliteration of its cavity, by an adhe- 
sion of its coats. — This is the general opinion of the 
Wanner in which hydrocele is cured, but Mr. Ramsdea 
asserts, that a radical cure may be effected without obli- 
terating the sac. I shall presently quote his words. 

OF THE PALLIATIVE CURE. 

As hydrocele is by no means a painful disease, many 
patients prefer submitting to the inconvenience it occa- 
sions, to encountering the pain of a surgical operation; 
by means of a suspensory bag the weight of the tumour 
is supported, and the excoriation of the neighbouring 
parts in some degree prevented. When the tumour 
however acquires a very large size, the inconvenience 



ELEMENTS OF SURGERY. *3i 

resulting from its bulk and weight cannot be obviated 
by any mechanical contrivance, and the water must be 
evacuated. The most convenient mode of performing 
this operation is to insert a common lancet into the tu- 
mour in such a situation as to avoid the testicle.* A 
small trochar may be substituted for the lancet, but it 
gives more pain. If the lancet be used, a probe, a 
grooved director, or what is still better, a small canula, 
should be introduced through the puncture as soon as the 
lancet is withdrawn ; if this be not done, the skin of the 
scrotum is apt to slip over the puncture in the tunica va- 
ginalis, in such a manner as to prevent the v ipe 
of the fluid ; the aperture through the skin no h 
corresponding with that in the sac, the water escapes into 
the cellular texture, and cannot be evacuated. 

After drawing off the water a small piece of adhesive 
plaster, or a dossil of lint, is to be placed upon the wound, 
and a suspensory bag applied over the scrotum. In ge- 
neral the wound heals very readily, but in some instances 
it inflames and suppurates, and effects a radical cure of 
the disease ; this is however not very frequent. Mr. Pott 
has known the simple operation of tapping a hydrocele, 
attended with fatal consequences, owing to the peculiari- 
ty of the patients constitution. 

In some cases the water when once evacuated does 
not collect again, even though no obliteration of the ca- 
vity takes place. This is, however, a very unusual oc- 

• In general the testicle is situated at the posterior and inferior part of the 
tumour ; the usual place of drawing off the water is al the middle of the ante, 
rior part of the scrotum, but a difference is observed in this respect, and Mr. 
Hunter recommends to ascertain before inserting the lancet, the precise situa- 
tion of the testis, which may be done by pressing upon the different parts of the 
tumour, as a wry peculiar sensation is produced by squeezing the testicle. In 
this way Mr. Hunter once succeeded in drawing off the water of a hydrocele, 
by inserting 'he lancet where the testicle is generally found. Several previous 
attempts having been made by other surgeons, who inserted the trochar at the 
uaual place, where it enU-red the testicle. 



132 ELEMENTS OF SURGERY. 

currence, although in recent cases of hydrocele I have 
known several successive tappings to effect a radical 
cure, and this in two or three instances. 

OF THE RADICAL CURE. 

To produce inflammation and adhesion of the sides of 
the tunica vaginalis, a variety of operations have been 
employed. The principal of which are, an extensive 
incision into the cavity containing the fluid—- The exci- 
sion of the tunica vaginalis — Caustic applied so as to 
occasion a slough extending through the scrotum into 
the cavity — The introduction of a tent or seton — Cer- 
tain external discutient applications — The injection of 
wine or other stimulating liquors, and the introduction 
of flour through a small incision into the cavity, after 
evacuating its contents. 

The two latter are most commonly employed at the 
present time, and I shall not describe any of the others, 
because they are unnecessarily severe, and have justly 
gone into disuse. 

The method of treating hydrocele by injection has 
been lately recommended in very strong terms by Sir 
James Earl. It was first performed I believe by Mr. 
Lambert, a French surgeon, who injected a solution of 
corrosive sublimate in lime water. A variety of other 
fluids have been tried, but the best is believed by Sir 
James Earl, and by the generality of surgeons to be 
wine. It is sufficiently irritating to effect the purpose, 
and not so irritating as to occasion unpleasant effects. 

Sir James Earl recommends about two thirds of wine 
(common port wine) to one third of water. If the parts 
appear insensible and no pain is produced, he recom- 
mends, to add to the proportion of wine. If on the con- 
trary the pain be very great, especially in recent cases, 
the proportion of water should be increased. 



ELEMENTS OF SURGERY. 



133 



Mr. Ramsden although he advocates the operation of 
Sir James Earl, insists that the obliteration of the sac 
does not in all cases succeed it. He remarks, " I am 
ready to allow that when inflammation is induced to a 
certain extent, the annihilation of the cavity of the tunica 
vaginalis will be a necessary consequence ; but I know 
also that the radical cure of the hydrocele may be ef- 
fected (and is so in a large majority of cases) by excite- 
ment of that sacculus without any such extinction of its 
cavity.*' His theory is, that inflammation induces a sup- 
pression of the action of the secretory vessels which 
pour out the fluid, even when the degree of inflammation 
is insufficient to produce adhesions, and consequent ob- 
literation of the cavity. 

It has been recommended by Mr. Pott, in every case 
previously to performing any operation for the radical 
cure of hydrocele to draw off the water, in order to exa- 
mine the testicle and ascertain whether it be diseased or 
sound. Sir James Earl urges another reason for this, 
which is that the size of the tumour may in this way be 
considerably diminished, and therefore the operation for 
the radical cure will be less severe. He considers the 
remark as chiefly applicable to large hydroceles ; when 
the tumour is of a smaller size, the previous tapping is 
unnecessary. 

The usual method of performing the operation is to 
seat the patient upon a chair, and to tap the tumour with 
a trochar at the anterior part a little below the middle, 
care being taken to avoid the testicle and any large vein, 
of which a great many .are commonly visible in the scro- 
tum — when the whole of the water has flowed through 
the canula of the trochar, a syringe or bladder and pipe, 
which lit the canula are to be employed, and the cavity 
distended with the wine and water to its former dimen- 
sions. This fluid is to remain till considerable pain in 
the back and loins is perceived. In general, this pain 



134 ELEMENTS OF SURGERY. 

is very severe in five or six minutes, but it is sometimes 
necessary to keep it in longer, and sometimes it cannot 
be borne so long. I have known fainting ensue, and 
immediately on injecting the wine the patient has drop- 
ped from his chair. When the wine has been suffered 
to remain a sufficient length of time in the sac, it is al- 
lowed to pass off again through the canula, and the pa- 
tient is placed in bed. 

The subsequent treatment consists in regulating the 
degree of inflammation ; if it be very severe bleeding and 
purges, with a low diet are to be prescribed, and if 
on the contrary too moderate, an opposite plan is to be 
pursued, and a generous diet and wine are to be di- 
rected. 

The only cautions necessary in performing the opera- 
tion arc to be certain that the canula is within the tunica 
vaginalis when the wine is injected, and to avoid irri- 
tating the testicle by the trochar or lancet, and also by 
moving the end of the canula so as to rub its surface. 

In order to prevent the canula from slipping out of 
the cavity, it should be inserted upwards to a consider- 
able distance, and held in the same situation during the 
operation by pressing it between the fingers which are to 
enclose also the skin of the scrotum at the part where it 
entered so that the scrotum maybe pinched between the 
finger and the canula. From a neglect of this precau- 
tion the cellular texture of the scrotum has been injected 
instead of the tunica vaginalis, and extensive mortifica- 
tion iias been the consequence. 

This operation by far the mildest which has been 
found successful, does not invariably succeed, and this 
is a good reason for rejecting a modification of it lately 
proposed, by substituting warm water for wine.* I have 

* I have seen this plan proposed in a late European publication, but I am 
unable to recollect with certainty by whom it was suggested, I think by Mr. 

Wheatly. 



ELEMENTS OF SURGERY. 135 

known one case in which this practice succeeded, but 
certainly the wine is preferable because more stimula- 
ting, and because its degree of stimulation can be varied 
according to circumstances. In a large majority of in- 
stances the injection of wine will be found to effect the 
cure. If it should however fail, it can be repeated, or 
Mr- Hunter's operation may be substituted. 

This consists in making an incision an inch in length, 
into the tunica vaginalis at the anterior part of the scro- 
tum, evacuating the water, and filling the cavity with 
balls of dough, the aperture being held open by two 
hooks in the hands of an assistant. The patient being 
placed in bed generally a good deal of pain and fever 
supervene; suppuration takes place, and the flour is 
washed out with the pus. The cavity gradually con- 
tracts, and granulations form, which uniting, completely 
fill it up. 

This is a most certain and effectual cure for hydro- 
cele, and although more severe than the injection, is by 
no means comparable in severity to the incision, seton, 
or caustic, formerly employed. 1 have seen it performed 
in several instances, always with success and without 
any very distressing consequences. 

Congenital hydrocele is that species of the disease 
in which the tunica vaginalis retains a communication 
with the general cavity of the abdomen. Desault in these 
cases injected red wine, making pressure at the abdomi- 
nal ring to prevent its entering the abdomen. He was 
successful, and never occasioned peritoneal inflamma- 
tion. In one instance in which it was connected with 
congenital hernia, he performed the operation, the tuni- 
ca vaginalis was obliterated, and both hernia and hydro- 
cele were radically cured. 

The principal chronic enlargements of the testicle 
which are called by the general name of sarcocele 



136 ELEMENTS OF SURGERY. 

have been briefly noticed in the chapter on cancer, 
is proper to state in this place, however, that these en- 
largements often accompany hydrocele, and in many 
cases forbid the use of any of the remedies proper for the 
radical cure of the latter disease. In these cases (which 
are denominated hydro-sarcocele) frequent evacuation of 
the fluid is the safest and best mode of treatment. 

As I shall not treat of any of the forms of venereal 
disease in the present work, I cannot enter on the con- 
sideration of hernia humoralis, or swelled testicle, re- 
sulting from gonorrhoea. It may not, however, be im- 
proper to state that the repeated introduction of bougies 
is frequently found successful in reducing enlargements 
of the testicle which have originated from this source, 
even in cases where they appear to exist independently 
of strictures in the urethra. 

In all obstinate cases of sarcocele which resist the 
usual discutient remedies and become painful it is the 
safest plan to remove the affected part. 



ELEMENTS OF SURGERY. 137 

CHAPTEH XVII. 

Of Hematocele. 

This term has been used by surgeons to express those 
swellings of the scrotum which are occasioned by effused 
blood. The blood may be situated in the common cel- 
lular texture of the scrotum differing in no respect from 
common ecchymosis ; or it may be situated in the tunica 
vaginalis. Ecchymosis in the substance of the testis, 
constitutes another species of hematocele. 

The cause of this affection is a rupture or puncture of 
a blood-vessel, and the remedies are such as promote the 
absorption of the effused blood — the treatment is similar 
to that employed in cases of ecchymosis ; cold applica- 
tions, moderate pressure, and occasional purging. 

It sometimes happens that a large quantity of blood 
is collected in the tunica vaginalis, after the tapping of 
a hydrocele ; this blood should be evacuated by a punc- 
ture, and the scrotum supported in a suspensory bag. 
I have known the whole scrotum suddenly become dis- 
tended with effused blood from the rupture of the tunica 
vaginalis, in a case of hydrocele. The patient and his 
surgeon in this case were greatly alarmed by the new ap- 
pearance of the parts, which became tense, and assumed 
a dark purple colour, indicative, as they supposed, of 
gangrene. No such consequence however followed. 
The encysted became an anasarcous hydrocele, the wa- 
ter mixed with extravasated biood was diffused through 
the cellular texture of the scrotum ; in a few days the 
aperture through which it had escaped, healed up, and 
the purls resumed their usual appearance ; the encysted 
hydrocele returning, the extravasated blood and water 
wore absorbed. 

Vol. II T 



138 ELEMENTS OF SURGERY, 



CHAPTER XVIII. 



Of Varicocele and Circocele.* 

Varicocele consists in a varicose or morbidly dilated 
state of the veins in the scrotum. In general this is the 
consequence of other diseases of the neighbouring parts, 
and these are the chief objects of attention, as the en- 
largement of the veins occasions no particular inconve- 
nience. 

Circocele is a varicose state of the spermatic veins, 
It occurs in a great majority of cases in the spermatic 
cord and testicle of the left side, in consequence, as Mr. 
Home supposes, of the circuitous route which the blood 
of the left testicle pursues, in its return to the vena cava; 
the spermatic vein commonly terminating at a right angle 
in the left emulgent. It sometimes occasions a diminu- 
tion of the testicle. The tumour occasioned by this dis- 
tention, is sometimes very considerable ; it is generally 
greatest at the lower part near the testicles. The dis- 
ease has sometimes been mistaken for omental hernia, 
but it may always be distinguished in the manner pro- 
posed by Mr. Astly Cooper ; he directs the patient to 
be placed in a horizontal posture, and the veins to be 
emptied by pressure, after which the surgeon is to place 
his fingers on the upper part of the abdominal ring, and 
desire the patient to rise. If the disease be hernia, no 
return of the tumour can take place whilst the pressure 
is continued, whereas this pressure, encreases the swel- 

* These terms are often promiscuously used, but they may very properly be 
applied with more precision to express two very distinct morbid afi'ections. 
Celsus and after him the classical Mr. Percival Pott applied the term circocele. 
in the sense which I have adopted. 



ELEMENTS OF SURGERY. 139 

ling in cases of circocele, by interrupting the passage of 
the blood through the veins. In addition to this we are 
generally able to feel distinctly, in cases of circocele, the 
round figure of the convoluted vessels at the top of the 
testicle. 

In general the disease occasions but little inconveni- 
ence, and the patient is not anxious for a cure ; but when 
distention is very great and the weight of the tumour 
considerable, severe pain in the back and loins are the 
consequence. 

In the treatment of this complaint, a radical cure is 
seldom attempted. A suspensory bag is generally re- 
commended, and the old remedy of castration which has 
been too often performed for the cure of circocele, is 
now justly disused. 

Mr. Home has tied up the spermatic vein for the cure 
of this disease, but the symptoms consequent were ex- 
ceedingly severe, and unless in cases of enormous dis- 
tention of the veins, the operation ought not to be per- 
formed. 



140 ELEMENTS OF SURGERY. 



CHAPTER XIX. 



Of Strictures in the Urethra. 



A stricture of the urethra consists in a contraction, or 
diminution of diameter in a part of this canal. It is 
either spasmodic and temporary, or permanent. 

The spasmodic stricture consists in a contraction 
of the urethra at a particular part, depending upon spasm, 
and subsiding when that spasm ceases. 

The permanent stricture is attended with a change 
in the structure of some part of the urethra, generally in 
the first instance a very small part, not more than would 
be forced together by a pack thread tied on the outside 
of the canal. The two cases are occasionally blended, 
and spasm supervenes upon a permanent stricture. 

Strictures in their commencement are in general spas- 
modic, and Mr. Hunter and Mr. Home consider them in 
the first stage, as a wrong action of the muscular fibres 
of the urethra, which at times completely subsides, and 
leaves the parts unchanged. As the disease progresses 
the canal at the affected part loses the power of expand- 
ing again to its original diameter, and thus becomes per- 
manently contracted. 

Permanent strictures are generally liable to spasm, as 
we find patients affected with them, frequently suffering 
a complete suppression of urine, in consequence of ex- 
posure to cold, or the intemperate use of Avine, of violent 
exercise, or similar causes of an irritating nature. 

Mr. Charles Bell in a recent work on the diseases of 
the urethra, denies that the urethra « is muscular or ca- 



ELEMENTS OF SURGERY. 



141 



pable of contracting, and consequently declares Mr. 
Hunter's opinion of the origin and nature of strictures in 
the urethra to be unfounded. He has endeavoured to 
prove that the membrane of the urethra is destitute of 
muscular fibres by experiment : — having introduced an 
ivory ball into the urethra, he directed the man who was 
the subject of the experiment to expel it, which he Mas 
unable to do. He imbued the ball with stimulating ar- 
ticles as soap and spirits, but still there was no power 
in the urethra to retain the ball or to push it forth. The 
ball could only be expelled by the urine behind it, or by 
the ejaculator seminis. An experiment was made to as- 
certain the action of the urethra upon fluids. Mr. Bell 
found that when the urethra was distended with water 
to a distance of five inches from its external orifice, the 
patient was utterly uuable to empty it by any effort of the 
parts. 

Mr. Bell's experiments do not appear to me by any 
means to establish the point; because the urethra is evi- 
dently capable of emptying itself, a fact which is readily 
proved by distending it with urine, keeping the external 
orifice closed ; if at this time a finger be placed in such 
a manner as to compress the urethra three or four inches 
from the end of the penis, and the orifice of the urethra 
be now opened, a jet of urine takes place, and that part 
of the urethra is emptied. It is evident in this case that 
the urine from the bladder being intercepted, nothing but 
the contraction of the urethra could evacuate its con- 
tents. 

Mr. Bell is right, however, in ascribing much to in- 
flammation, in the formation of stricture, but when he 
asserts that the sole origin of all strictures in the urethra 
is inflammation, he goes too far. 

Wishing to avoid all controversy on this, as on all 
other occasions, I pass over many arguments which 
might be advanced to prove the contractile power of 



142 ELEMENTS OF SURGEHY. 

a stricture in the urethra, hut of the fact I think few 
surgeons who are conversant with the subject will enter- 
tain a doubt. It often happens in practice that a stric- 
ture which commonly admits a large bougie shall sud- 
denly deny to the efforts of the surgeon a passage to 
every instrument. After a time this temporary barrier 
ceases as suddenly as it came on, and again the large 
bougie gains a ready entrance. The change is too sud- 
den to be ascribed to inflammation ; it must be owing to 
spasm. Every surgeon of experience must have seen 
bougies expelled the urethra by the action of this canal. 

This progress of a stricture of the urethra is in gene- 
ral very slow at first ; I have known a person insensible 
of its existence even when the stream of urine was re- 
duced to one fourth its natural size, so gradual and slow 
had been its increase. After a time, however, it ad- 
vances more rapidly. The urine is voided very fre- 
quently, and great efforts of the bladder are required 
to pass it ; it comes out in a spiral or forked stream, 
and a tenesmus urines or straining continues after this 
viscus is emptied. 

When the stricture is in this state, a debauch with 
wine ; exposure to cold ; and a variety of other occasional 
irritations aggravate the disease, and sometimes occasion 
a suppression of urine. Mr. Home ascribes this to a 
closure of the urethra at the strictured part by spasm, 
and I think it gives great plausibility to his opinion, that 
the remedies most successful in removing the complaint 
are such as are generally employed in the treatment of 
spasmodic diseases, as opium, the warm bath, &c. 

Strictures are very often attended with a discharge 
from the urethra ; a dull heavy pain in the back and 
loins attends the complaint, and many of the symptoms 
of stone are occasionally experienced. 

The bladder is sometimes greatly thickened in conse- 
quence of strictures. Sometimes it inflames and dis- 



ELEMENTS OF SURGERY. 143 

charges mucus and pus ; in some instances a discharge 
takes place of a whitish adhesive viscid substance, which 
Mr. Home pronounces to be a vitiated secretion of the 
prostrate gland, an opinion founded upon dissections. 

In some patients a nocturnal emission of semen at- 
tends, and in others the discharge of semen is prevented 
by the obstruction. The urine is often turbid, deposit- 
ing a sandy sediment. 

All the symptoms of stricture, are greatly aggravated 
by accidental circumstances of an irritating nature, es- 
pecially by exposure to cold. In some rare instances 
peritoneal inflammation and death have resulted from 
strictures of the urethra. 

If the stricture be suffered to go on without any in- 
terruption from the surgeon, it sometimes produces a 
complete obliteration of the urethra, and suppuration 
takes place behind it, forming an abscess which opens 
through the external teguments, and a passage is thus 
formed for the escape of the urine forming a fistula in 

PERINEO* 

Fevers and shiverings frequently attend the progress 
of strictures, accompanied with nausea, vomiting and 
indigestion. In some cases these symptoms come on in 
consequence of the introduction of bougies, or of other 
irritation. 

The appearance of strictures on dissection vary very 
much. They sometimes occupy only a small portion of 
the urethra, and at other times an inch or more of its 
length is found irregularly contracted, forming a wind- 
ing canal. Sometimes the appearance is that of a mere 
narrowing of the canal, and in other cases a complete 
ridge projects into the urethra. The bladder after death 
is found greatly thickened, and sometimes the ureters 
and kidneys are diseased. 

In some cases one, and in some several strictures ex- 
ist. Mr. Hunter lias known six in one urethra. 



144 ELEMENTS OF SURGERY. 

The most frequent situation of stricture is at the bulb ; 
Mr. Hunter says he has never seen a stricture at the 
prostrate gland, but they occasionally form in every 
other part of the canal. Mr. Home thinks the order of 
frequency greatest at six and a half or seven inches from 
the external orifice, that is at the bulb of the urethra ; 
and next about four and a half inches. I have seen the 
very extremity of the canal affected with stricture. 

The causes of stricture in the urethra, are not very 
well understood. Sometimes they result from irrita- 
tion, and probably from gonorrhoea and the use of irri- 
tating injections, although Mr. Hunter doubted whether 
these were frequent sources of the disease. Mr. An- 
drews relates a case where it appeared to result from 
the gravel, in a child between five and six years of age.* 
Mr. Hunter has seen a stricture in a boy only four 
years old, and I have recently dissected a young man 
aged about nineteen, who from infancy had been afflicted 
with a stricture of the urethra, his bladder for some time 
before liis death, was not capable of holding more than 
two ounces of urine, and its coats were found more than 
half an inch in thickness. In general they occur without 
any evident cause, although as most men have had at 
some period of their lives, the venereal disease, they ge- 
nerally ascribe their strictures to this source. 

TREATMENT. 

The methods of treating strictures of the urethra in 
general use, are two ; the dilatation by means of bougies, 
and the destruction of the stricture with caustic. Dr. 
Physick has contrived another plan, and in some in- 
stances, has cut through the stricture. 

The introduction of bougies to dilate the stricture, al 
though considered by Mr. Hunter, as affording only a 

Andrews on Strictures, p. 8. 






ELEMENTS OF SURGERY. 145 

temporary relief, succeeds no doubt in curing completely 
a great many cases of this complaint. The manner in 
which bougies act upon the stricture, is not simply by 
dilating mechanically the contracted passage, but by 
pressure they produce ulceration, and the stricture is 
destroyed by the absorbents. 

In this country it is essential for the surgeon to be ac- 
quainted with the manner of preparing bougies, because 
those which are imported and manufactured for sale are 
very unsafe, and are totally unfit for the purpose for 
which they are designed. They are unsafe because 
being formed generally of old linen they are apt to break, 
and in this manner may lodge in the bladder or urethra, 
and occasion great inconvenience, and they are unfit for 
use, from their bad form, and from the improper sub- 
stances of which they are composed. 

The best materials for the construction of bougies are 
fine new linen and pure yellow bees wax. The linen 
should be cut into pieces about twelve or fourteen inch- 
es square, and dipped into melted wax; it should be 
taken out in such a manner that the wax may drip off at 
one end, and not more by one corner than another ; in 
this manner the linen will receive a coat of wax of a 
uniform degree of thickness, excepting that the depend- 
ing portion will be more thickly coated than the superior 
part ; the linen is to be cut into strips of a proper width, 
care being taken always to cut in the transverse direc- 
tion, because as there is more wax upon the lower than 
the upper part, there would be an irregularity in the 
form of the instrument if this can ion were neglected. 
The strip of waxed linen or bougie plaster is next to be 
cut of a proper shape, so that when rolled up it may ta- 
per to a point. The form which I prefer, is to have the 
bougie slightly conical, through its whole length, but to 
taper at the end, very quickly to a point. The sinall- 
jiess of the point enable* the surgeon to insinuate it into 
Vol. II. U 



146 ELEMENTS OF SURGERY. 

the stricture and the conical form gives it a degree of 
firmness gradually increasing from the point to the oppo- 
site extremity. The art of rolling up the bougie and 
of giving it a proper point is to be acquired by habit, 
and need not be particularly described. I will only re- 
mark, that a marble slab, or a polished mahogany table, 
and a broad spatula, or knife, are all the tools necessary 
for this purpose, and I conclude this part of the subject 
by recommending to the practitioners of this country the 
preparation of their own bougies. 

Previously to their introduction they should always be 
covered with sweet oil. 

In order to ascertain the existence of a stricture in the 
urethra, it is necessary to pass a large bougie with a 
round extremity along the urethra ; the place at which 
it stops marks the situation of the stricture. A large 
bougie passes more readily than a small one as far as the 
stricture, because the point of a small bougie is apt to 
get entangled in the lacunae of the urethra. Mr. Charles 
Bell recommends for this purpose a ball or globe of sil- 
ver soldered upon a long probe. It has no advantage, 
however, over the common bougie. 

In passing a bougie, care should be taken to avoid 
pressing any part of the urethra, and the penis should 
be drawn forwards upon the bougie at the same time 
that the bougie is pushed gently on. 

It often happens that when the surgeon is first con- 
sulted, he finds the passage so small that no bougie can 
be passed through the stricture. In these cases it should 
be daily introduced down to the stricture and pressed 
against it with moderate force ; after repeated trials of 
this kind, the bougie will generally gain an entrance, 
and if even the smallest bougie be once passed through 
the stricture it can always be dilated so as to admit a 
larger one. The pressure should never be great, be 



ELEMENTS OF SURGERY. 147 

cause a false passage might be formed by too much vio- 
lence. 

The attempt to introduce a bougie often excites spasm 
in the stricture, and this retards and sometimes pre- 
vents the introduction of the instrument. Mr. Hunter 
advises in such cases to press the bougie gently against 
the stricture for a few minutes, when in general the 
spasm will subside. 

The bougie when first introduced should not be suf- 
fered to remain long ; after three or four minutes it 
should be removed. Its introduction should be repeated 
daily, and the time of its continuance gradually increas- 
ed ; it may at length be suffered to remain an hour or 
longer. The diameter of the bougie should also be 
augmented from time to time, until the structured pas- 
sage is dilated to its natural size. 

The use of the bougie should not however be entirely 
discontinued even when this is done, because the parts 
retain for a long time a disposition to contract, and this 
must be obviated by an occasional introduction of the 
instrument ; once in three or four weeks will be often 
enough for this purpose. 

Patients sometimes faint and become sick, and cover- 
ed with a cold sweat, when a bougie is first used, this 
however seldom occurs at the subsequent introductions. 

It often happens that bougies are completely inefficient 
in the treatment of strictures, and a long and steady per- 
severance in their use, produces very little if any dilata- 
tion of the diseased part. In such cases, and in all those 
cases in which the bougie cannot be introduced, and the 
passage is almost or entirely closed, the destruction of 
the stricture must be effected either by caustic or the 
lancet. 

Tlu', application of caustic was introduced by Mr. 
Hunter. Mr. Home has written extensively upon the 



148 ELEMENTS OF SURGERY. 

subject, and extols very highly this method of treating 
strictures. 

The best mode of applying the caustic I believe to be 
that recommended by Mr. Home : a bougie is to be pre- 
pared of a size which will pass readily down to the 
stricture ; into the end of this bougie a piece of lunar 
caustic (argentum nitratum) is to be fastened ; it is co- 
vered laterally by the bougie plaster, and is uncovered 
only at the extremity of the instrument. For the purpose 
of security I have always tied a fine cambric thread 
neatly round the linen which invests the caustic* 

The bougie thus armed is ready for use ; — the distance 
to which it is to be passed in the urethra is ascertained 
by passing another bougie down to the stricture, and 
marking upon the armed bougie the depth to which it 
had entered when in contact with the stricture. The 
armed bougie is now to be dipped into oil, and passed 
down to the stricture, it produces no irritation and in- 
deed scarcely touches the urethra until it arrives at the 
stricture. The caustic should be suffered to remain in 
contact with the stricture about a minute, and should be 
then withdrawn. The pain experienced is generally 
very slight, and the consequences by no means severe. 
The patient should be directed to make water after the 
removal of the armed bougie. A little blood will some- 
times be found to tinge the urine voided. The applica- 
tion is to be repeated once in forty- eight-hours, as often 
as may be necessary for the cure of the disease. It is 
seldom safe to use the caustic oftener, but in some cases 
where the sensibility of the parts is very much diminish- 
ed, Mr. Home has applied it every day. 

Mr. Whately has introduced a mode of destroying 



* The caustic should be nearly half an inch in length, and of about one-third 
of the thickness of the usual rolls of caustic. It is not easy to procure it of 
this shape, and the surgeon must either scrape it thin enough, or fuse the 
common lunar caustic and cast it in an iron mould. 



ELEMENTS OF SURGERY. 149 

mres by the application of the vegetable caustic al- 
kali. A piece of kali puvum as large as a pin's head* 
he directs to be placed in an indentation made by the 
Hail in the end of a bougie, and this bougie is to be pass- 
ed down to the stricture. The caustic dissolves very 
speedily in the fluids of the urethra, and thus destroys 
any part of the canal with which it comes in contact. 
For a particular account of this plan, I refer to Mr. 
Whately's publication, just observing, that it is, in my 
opinion, a most uncertain mode of operating, as it is im- 
possible to know on what part the caustic will dissolve, 
and as Mr. Charles Bell remarks, it will be much more 
likely to act on the hollows and depressions in the ure- 
thra, than on any natural or accidental eminences. 

Mr. C. Bell has constructed an instrument for the ap- 
plication of caustic to strictures, which consists of a hol- 
low globe with an aperture at the end, or side, fastened 
on a long probe. A portion of alkaline or lunar caustic 
placed in this aperture may be passed down to the stric- 
ture, but the mode of applying caustic recommended by 
Mr. Home I believe to be preferable to any other me- 
thod. 

The division of a stricture by means of a cutting in- 
strument, was first performed by Dr. Physick in 1795, 
and in several instances since that time, he lias repeat- 
ed the operation with success. The instrument em- 
ployed for this purpose is a lancet, concealed in a ca- 
nula ; when the stricture is situated anteriorly to the 
bulb of the urethra,, no danger or difficulty attends the 
division of it by means of this instrument, but if the 
stricture be situated at the bulb, a very accurate know- 
ledge of the anatomy of the parts will be necessary, and 
great caution in the operation. A small wound how- 
ever of the urethra, made with a sharp lancet, would oc- 
casion no great trouble, and would probably heal very 
readily. The urethra is generally distended behind the 



150 ELEMENTS OF SURGERY. 

stricture, and of course it is not easy to pass the knife in 
a wrong direction. After the stricture is cut through, a 
flexible catheter should be introduced and kept in the 
bladder three or four weeks ; after it is removed a bou- 
gie should be frequently introduced. 

The best method of treating spasmodic stricture 
with a view to a radical cure consists in applying 
caustic to the part. During the continuance of the 
spasm, bleeding, mercurial purges, opium, and the warm 
bath will be found useful. Emetics are also occasionally 
successful. Dr. Shaw of this city, succeeded in pro- 
curing relaxation of a spasmodic stricture bypassing on 
a bougie a leaf of tobacco (jown to the stricture. Nau- 
seating medicines are very advantageous. 

Within a few years many volumes have been written 
on strictures of the urethra. Several of these are highly 
valuable, among the rest I beg leave to refer the reader 
to the writings of Mr. Hunter, and to the excellent his- 
tory which Mr. Home has given of this subject. Mr. 
Whately, Mr. Charles I5ell, and Mr. Andrews have 
also written papers which contain very useful informa- 
tion. 

With respect to the mischievous effects said to have 
resulted from the use of caustic, I have no doubt that 
in many instances they have occurred, and the indiscri- 
minate use of caustic is therefore wrong. Where the 
stricture yields readily to bougies, they ought to be pre- 
ferred. Where it does not, the caustic should be sub- 
stituted, and if managed with proper caution, is I be- 
lieve very generally safe, though I have often known sup- 
pression of urine occasioned by it, and in one case a he- 
morrhage which reduced the patient to extreme debility, 
from which he never recovered. 



ELEMENTS OF SURGERY. 151 



CHAPTER XX. 



Of Fistula in Perineo. 

In consequence of an entire stoppage or great obstruc- 
tion to the discharge of urine from a stricture in the ure- 
thra, inflammation and ulceration take place behind the 
strictured part ; when the ulceration proceeds through 
the skin forming an outlet for the urine, the disease call- 
ed fistula in perineo is formed. 

The same circumstance also results in some cases 
from accidental injuries to the perineum which terminate. 
in ulceration communicating with the urethra. 

The urine in some cases becomes extravasated into 
the cellular texture in the vicinity of the urethra, and 
occasions violent inflammation and mortification. When 
the sloughs separate if the patient survive, a fistulous ul- 
cer remains. 

The first thing generally necessary in the treatment of 
fistula in perineo, is to dilate and remove the stricture 
which caused it. A bougie should be passed, and in 
many cases it will find a ready access to the bladder, 
the stricture having been destroyed by the ulceration. 
If, however, the stricture remain, an opening should be 
made through it by the use of caustic, and an elastic ca- 
theter introduced and kept in the bladder until the exter- 
nal sore heals, which will generally happen speedily in 
recent cases. 

In many instances, however, the fistula is by no means 
so readily cured — the urine escaping into various parts 
of the cellular texture of the scrotum produces abscesses 
and sinuses running in various directions. Theintcgu- 



152 ELEMENTS OF SURGERY. 

ments of the perineum and scrotum, are knotty, hard, 
and irregular, with one or more outlets for the urine. 

The cure in these cases is often difficult ; sometimes 
impracticable. It should be attempted, however, by 
destroying the stricture in the way already mentioned, 
and if this fails, by making a free opening externally 
into the urethra, in order to prevent the urine from en- 
tering the sinuses. The best method of doing this is to 
pass a silver female catheter, sound, or director, down to 
the stricture, and to make this project as much as possi- 
ble in the perineum. A probe should now be passed 
into the fistula and the catheter sought for. If it can be 
felt (which is not always the case) an incision should be 
made down upon it, and this incision should be carried 
farther towards the bladder so as to open the urethra 
freely between the stricture and the bladder ; but if the 
catheter cannot be felt by the probe passed into the fis- 
tula, then an incision is to be made directly upon the 
extremity of the staff or catheter, and the stricture will 
in this manner be cut through. A catheter should now 
if possible be passed into the bladder ; if this be not 
practicable, and the surgeon be unable to find the urethra 
behind the stricture which is often extremely difficult, 
in such a case it has been recommended to perform a 
more decisive operation. 

Mr. Charles Bell on this subject remarks : " It often 
happens that in these diseases of the perineum, the 
urine obtaining a free discharge by the fistulous open- 
ing, the original stricture is more and more contracted, 
and a considerable part of the canal is totally obli- 
terated. This contraction and increase of the length 
of the stricture is no doubt accelerated by the suc- 
cessive extension of the inflammation in the perineum ; 
and very often in this complicated state of the disease, 
there is a large quaggy swelling of the integuments of 
the perineum, great part of which it were better to take 



ELEMENTS OF SURGERY. 153 

away by a double incision in the first part of the opera- 
tion. 

" In this operation, one longitudinal incision in the 
length of the diseased integuments of the perineum, or 
two, including a portion of the diseased skin, may be 
necessary. In this the state of the parts must be our 
rule and guide. 

" Now the parts are to be pretty freely dissected, 
while we endeavour to make distinct the bulb of the ure- 
thra. The fistulous opening into the urethra is next to 
be sought for ; and a staff, or sound, or catheter, having 
been introduced into the urethra, down to the upper part 
of the stricture, the track of the diseased urethra, and 
the point of the staff is to be explored ; and if the urethra 
proves entirely diseased for some length, it is to be cut 
out. Now a bougie of the largest size is to be intro- 
duced from the wound, into the bladder, and another 
from the extremity of the urethra down to the wound. 
The parts are to be slightly dressed, and the patient put 
to bed. 

" After a few days, when suppuration has taken place, 
and the granulations are sprouting up about the bougie, 
it is to be withdrawn, and the catheter introduced along 
the whole length of the urethra; over which, if it be 
kept steady, and in a good situation, the parts will soon 
heal. 

ik After the first dressing, when we find that the in- 
flammation is not likely to run to any dangerous degree, 
we must dress it with a stimulating ointment, on slips of 
lint, and over this put a warm poultice, which will pro- 
mote healthy granulations." 

The fistulous ulcer is in some cases so indolent as to 
require the most stimulating applications to induce gra- 
nulations. In such cases caustics and escharotics are to 
be used. I have tiied the hare-lip suture in a case of 
large opening into the urethra at the perineum, but no 
Vol. II. X 



154 ELEMENTS OF SURGERY. 

advantage resulted, although the urine flowed entirely 
through an elastic catheter, and not a drop escaped at 
the wound, the edges of which had been pared off and 
kept in contact. This backwardness to granulate and 
heal, depends therefore not only on the escape of urine 
at the ulcer, but also on the change of structure in the 
part, which is very great; all appearance of corpus spon- 
giosum being in most cases lost, and succeeded by an 
indurated indolent substance. 

Fistulae in perineo sometimes contract to a very small 
size and appear to heal, and yet remain open, occa- 
sionally discharging urine during a number of years. I 
have had several patients with fistulas too small to ad- 
mit the finest probe, and these fistulae have remained 
open during life. 

Fistulas sometimes result from false passages formed 
by the improper use of the bougies used in treating stric- 
tures. For an account of this subject I refer to Mr, 
Hunter. 



ELEMENTS OF SURGERY- ±55 



CHAPTER XXI. 



Of Retention of Urine. 

A total obstruction to the discharge of urine situated 
at the neck of the bladder, or in the course of .the ure- 
thra, is the most usual cause of a retention of urine, but 
it sometimes results from a paralytic state of the bladder, 
and a consequent inability to expel its contents. As the 
latter is not strictly a surgical complaint, and as the in- 
troduction of the catheter is easily effected, it will only 
be necessary to treat of the former. 

When the sensation of a full bladder is perceived, if 
the patient be unable to evacuate his urine, great pain 
and violent straining efforts come on, the bladder gra- 
dually distends, and may be felt above the pubis, and 
swells in some cases so much that its fundus rises to the 
umbilicus. The abdomen swells and becomes tense 
and painful, hiccough, difficulty of breathing and cold 
sweats attend, the bladder inflames, and unless relief be 
obtained mortification follows. 

The causes by which the discharge of urine is pre- 
vented are various : inflammatory, and other swellings 
in the vicinity of the urethra, as hemorrhoidal tumours, 
abscesses, &c.-a stone in the bladder or urethra j-spasm 
at the neck of the bladder or in the urethra ;-a perma- 
nent stricture, with or without spasm ;-inflammation of 
the neck of the bladder ;-an enlargement of the prostate 
glands, &c. 

Retention of urine unless relieved, terminates in ge- 
neral by death ; but in some cases this event is protract- 
ed verv much. Where the obstruction does not enlirclv 



156 ELEMENTS OF SURGERY. 

close the urethra, urine after a time begins to flow off, 
and although the bladder remains very greatly distended, 
yet the partial evacuation prevents the fatal consequences 
of the distention, and the patient continues in this situa- 
tion sometimes for several weeks making water as the 
French express it " par regorgement." 

If the discharge, however, be totally precluded, still 
death is not absolutely inevitable, because mortification 
may take place in a particular spot without proceeding 
to any considerable extent. At this mortified part the 
urine escapes, and most generally the part which morti- 
fies first is situated in the vicinity of the neck of the 
bladder, so that the urine Jbecomes extravasated into the 
neighbouring cellular texture, and fistula in perineo is 
the consequence. Sometimes the mortification is seated 
at the posterior part of the bladder and extends through 
the coats of the rectum, and the urine is suddenly in con- 
sequence of this, evacuated per aimm. Instances have 
occurred in which the bladder has burst (mortification 
having probably preceded) at its anterior part, and the 
urine has been discharged by an abscess at the umbili- 
cus. In other instances the urine escapes into the ca- 
vity of the abdomen and produces death. 

The ureters and kidneys become affected in conse- 
quence of the interruption to the discharge of urine, and 
they swell very much and become distended with this 
fluid. 

TREATMENT OF RETENTION OF URINE. 

This depends greatly upon the cause of the evil. If a 
stone in the bladder have interrupted the discharge of 
urine by falling over the neck of the bladder, a change 
of posture will generally relieve the symptom. If a small 
calculus be lodged in any part of the urethra, this should 
be extracted by means of an eyed probe bent at its per- 



ELEMENTS OF SURGERY. 157 

ibrated extremity into a hook, or by means of long for- 
ceps concealed in a canula (an instrument employed for 
that purpose by Mr. Hunter,) or lastly, by cutting down 
upon the stone and removing it through the wound. 

The most frequent obstruction, however, in the ure- 
thra is a stricture, either in a state of inflammation, or 
aifected with spasm. 

To ascertain the state of the canal it is best to intro- 
duce a bougie. In some instances this succeeds, and 
the urine flows as soon as the instrument is retracted, 
though it had not entered the bladder, but simply dilated 
the stricture. Should this fail, an elastic catheter should 
be introduced and passed as far as it will go without 
force ; should it enter the bladder, the urine is evacuated 
through it. 

At the time that these efforts are made, the patient 
should be freely bled, a mercurial cathartic should be 
taken, and he should be placed in a warm bath. Eme- 
tics and nauseating medicines have in some cases suc- 
ceeded in relieving a suppression of urine. Opium in 
considerable doses is to be next given if these remedies 
fail. It may be administered by clyster, or by the mouth. 
It has been recommended by Mr. Weldon to administer 
tobacco in infusion, perhaps its local application to the 
urethra and neighbouring parts would in some cases suc- 
ceed. 

The great reliance of the surgeon, however, in all 
cases of retention of urine is upon the catheter, and the 
introduction of this instrument is an object of immense 
importance to the safety of the patient, and of propor- 
tionate interest to the surgeon. I know no disease in 
the treatment of which dexterity and science are more 
esseutial than in the present, and there are very few in 
which more mistakes have been committed, or where the 
consequences of deficiency in the skill or knowledge of 
a practitioner are more serious, and fatal. In the inte 



158 ELEMENTS OF SURGERY. 

rior of our country there is reason to believe that mauy 
valuable lives are annually lost from no other cause than 
a want of proper medical assistance in cases of retention 
of the urine. 

Catheters are tubes adapted to the purpose of drawing 
off urine. Until within a few years they were generally 
made of silver, and of course were incapable of altering 
their shape when passed into the urethra ; the importance 
of flexibility in this instrument induced the older sur- 
geons to construct catheters of silver wire rolled in a 
spiral form, and polished smoothly on its external sur- 
face. Of late years a flexible metallic compound con- 
sisting chiefly of tin has been formed into catheters, some 
of which possess great flexibility. A French family of 
the name of Bernard, are in possession, however, of a 
composition for the construction of catheters far prefer- 
able to every other hitherto in use. The instruments 
prepared by Bernard have been supposed to consist of 
elastic gum. I do not myself believe that much if any 
elastic gum exists in the catheters manufactured by Ber- 
nard, because I have seen catheters made of elastic gum 
and they had no resemblance to those of Bernard ; they 
were useless from their too great flexibility. A web of 
silk forms the basis of the instrument, and this silk is 
varnished with a peculiar secret composition, which when 
dry is hard and susceptible of a fine polish, and the in- 
strument remains in the urethra a week or ten days 
without producing much irritation, and without becoming 
rough or being in any degree dissolved — properties as I 
believe, peculiar to the French catheters, the best of 
which are those prepared by Bernard.* 

A great many catheters have been made in imitation 
of the French. Those made in England are much more 

* It Is singular that Mr. Charles Bell should declare at the present day, that 
« in the hands of a dexterous surgeon the silver catheter is in general preferable 
to every other ;"— The surgeon who uses it should be also a " dexterous" silver- 
smith. 



ELEMENTS OF SUBGERY. 159 

highly finished, and for the mere purpose of drawing off 
the urine they answer extremely well, but when left in 
the urethra they become rough, and finally dissolve in 
the urine and mucus. 

Dr. Physick has made a great number of experiments 
with a view of discovering some composition possessing 
the requisite flexibility, and remaining insoluble in urine. 
A cylindrical silk web, wove by the whip makers upon 
wire of different sizes may be readily coated with var- 
nish, and when dried is easily formed into a catheter. 
Copal varnish may be used for this purpose, and a ca- 
theter well adapted for drawing off urine can be made 
without difficulty ; the surface being polished by rubbing 
it with pummice stone. This instrument, however, Dr. 
Physick found becomes speedily rough when allowed to 
remain in the urethra, and no other composition which 
he used possessed the properties combined in the French 
catheters, nor have the labours of others been more suc- 
cessful, for though very numerous attempts have been 
made to contrive a substitute for this instrument they 
have all failed. 

I shall dilate upon this subject no farther than to men- 
tion a mode of preparing an extemporaneous catheter 
which under certain circumstances, may prove a very 
useful instrument to the country practitioner. It consists 
in regularly extending the spiral wire of the suspenders 
which form at this time an article of every gentleman's 
dress till it becomes of sufficient length. This wire is 
afterwards to be covered with bougie plaster, and a hole 
cut near the end ; being properly rolled and prepared 
like a bougie it forms a very tolerable catheter. Dr. 
Physick in a case of emergency where no other catheter 
was to be procured, contrived this instrument, and on a 
similar occasion I have once found it extremely useful. 
1 find, however, that Mr. Daran was in the habit many 
years ago of preparing a catheter somewhat in the same 



160 ELEMENTS OF SURGERY. 

manner, by enveloping one of the old catheters formed 
of spiral silver wire in bougie plaster. 

It is difficult to give any general rules for the introduc- 
tion of the catheter. When the flexible catheter is used, 
it is only necessary to pass it gently onward drawing the 
penis at the same time forward. When this fails, and the 
stilet of wire is introduced in order to give to the instru- 
ment a greater degree of firmness, which is often necessary, 
then great caution must be used to avoid forming a wrong 
passage, by lacerating the urethra. Much is to be done by 
varying the form of the instrument. I have myself been 
accustomed when attempting to pass the catheter, to pro- 
vide a great number of wires curved in different forms, 
and when one has failed I have without delay substi- 
tuted another; it is astonishing how greatly the suc- 
cess of the operation will in some cases be influenced by 
a slight alteration in the shape of the stilet. In addition 
to the usual curve of the stilets I have found great ad- 
vantages from different lateral curvatures near the point 
of the instrument. In general no great difficulty is ex- 
perienced in passing the catheter through the anterior 
part of the urethra, the greatest difficulty is at the bulb 
of the urethra, or at the prostate gland, or neck of the 
bladder. It is probably of no great consequence whether 
the instrument be passed with the convexity towards the 
abdomen, or towards the perineum, it is at all events 
very easy when one fails to try the other. If the opera- 
tion fail in an erect posture, it should be tried in a re- 
cumbent one, and vice versa; Mr. Hey prefers the re- 
cumbent position and in most instances it is as conve- 
nient as any and in old or debilitated patients should be 
preferred. 

The common obstacle to the passage of the catheter in 
that part of the urethra which is anterior to the prostate 
gland is a stricture, and the mode of treating this has 
been already detailed. A difficulty often arises from the 



ELEMENTS OF SURGERY. 161 

enlargement either chronic or inflammatory of the pros- 
tate gland ; to surmount this obstacle the catheter should 
be curved very much at the point, even more than has 
been recommended by Mr. Hey ; much more than is re- 
commended by Mr. Charles Bell. 

In the succeeding plate I have drawn the shape of a 
catheter which I succeeded in introducing into the blad- 
der of an old gentleman with an enlarged prostate, after 
being baffled in every other attempt ; it is perhaps as 
much bent as will in any case be found requisite, and 
yet not more so than in certain instances will be re- 
quired. 

Mr. Hey accidentally discovered a mode of increasing 
the curvature of the flexible catheter by retracting the 
stilet whilst in the urethra, a practice long used and for 
many years taught by Dr. Physick, and which in some 
cases is very successful, by elevating the point of the in- 
strument above the prostate gland. 

As the chronic enlargement of the prostate in old per- 
sons is one of the most important and frequent cases 
which calls for the introduction of the catheter, I shall 
mention under the present division of the subject a mode 
of relieving retention of urine which sometimes succeeds 
when most others have been tried in vain. 

It often happens not only in cases of stricture, but also 
of enlarged prostate, that a bougie will gain admittance 
su llie bladder when neither a stiff nor a flexible cathe- 
ter can be introduced. The plasticity of the bougie 
when formed of pure bees- wax and linen, is much great- 
er than that of the most flexible catheter, and it assumes 
(lie form of the part where the obstruction is seated, adapt- 
ing itself to every curve and contraction in the urethra^ 
in such a manner that in many cases it may be gradually 
insinuated into the bladder when other instruments can 
not be passed. 

Vol. H. Y 



162 ELEMENTS OF SURGERY. 

Ill a case of retention of urine which occurred in the 
Pennsylvania Hospital in the year 1796, Dr. Physick 
was able to introduce a bougie, but no urine followed it, 
and his attempts to pass the catheter were completely 
abortive ; he immediately fastened the point of a bougie 
upon the extremity of an elastic catheter, and very rea- 
dily passed the instrument into the bladder and eva- 
cuated the urine. In a very great number of instances 
which have subsequently occurred the same method has 
proved successful. 1 consider this one of the greatest 
improvements which the catheter has ever received and 
shall briefly describe the mode of attaching a bougie 
point to a flexible catheter. 

A French catheter of the middle size is to be provided, 
and its point cut oil', leaving a continued cylindrical ca- 
nal through it. A piece of bougie plaster between two 
and three inches long, is to be cut into a proper shape, 
for forming a conical point to the instrument. When 
this plaster is rolled sufficiently to fill the cavity of the 
bougie, a slit half an inch long is to be made in its low- 
er end, after which the part rolled up, is inserted into 
the catheter, and the other half is wrapped round its out- 
side and fastened by tying a cambric thread neatly round 
it. In order to secure still more effectually the bougie 
point from slipping oft', and to extract it, in case this ac- 
cident should happen, a strong thread is passed through 
the bougie and fastened to the outer extremity of the 
catheter. 

The opposite plate illustrates the construction of the 
instrument. 

A. Represents the waxed linen or bougie plaster, cut 
into the proper form. 

B. Represents the same plaster rolled so as to form a 
plug to enter the extremity of the catheter. 

C. The bougie point rolled around and attached to the 
catheter. 



/ / i if. xv ii i 




ELEMENTS OF SURGERY. 163 

The string d, is intended to give greater security to 
the instrument, and in case of a separation of the point; 
from the catheter it would serve for the extraction of the 
former. Dr. Wistar generally passes the string through 
the catheter in the manner represented at e, which is 
equally secure and much neater than the other mode. 

The bougie pointed catheter succeeds in a variety of 
cases in which no other instrument can be introduced. 
In cases of enlarged prostate gland it is particularly suc- 
cessful, and where a considerable portion of the urethra 
is tortuous from strictures, it can be passed with more 
ease than any other catheter. 

If, however, every attempt to pass a catheter fail, 
another mode of gaining access to the bladder is occa- 
sionally in our power by perforating the stricture in the 
manner already mentioned. 

The instrument for performing this operation is a ca- 
nula or catheter, curved in such a manner as to pass rea- 
dily as far as the stricture ; in this canula is concealed a 
lancet capable of being protruded when necessary. The 
operation is to be performed by introducing the instru- 
ment as far as it will go, and then the lancet is to be 
protruded. In some cases the obstruction is situated 
beyond the bend of the urethra and in these cases, in or- 
der to guard against all danger of wounding any other 
parts except those intended, the handle of the instrument 
is to be depressed as low as possible, and when it is push- 
ed onward, it will be found to have divided the stric- 
ture and urine will generally escape through the ca- 
nula. The lancet is immediately to be retracted and the 
urine evacuated. A catheter must afterwards be intro- 
duced and left in the bladder until the new passage heals 
up. This very important operation which was contrived 
and has been repeatedly performed by Dr. Physick, has 
never been followed by any unpleasant consequences, 
and it has in several cases obviated the necessity of 



164 ELEMENTS OF SURGERY. 

puncturing the bladder, an operation which Dr. Physick 
has never been obliged to perform, having always suc- 
ceeded by some of the preceding methods in drawing off 
the water. 

The success of Dr. Physick in this particular, during 
twenty years of extensive practice is a strong argument 
in favour of Mr. Abernethy's opinion that the tapping of 
the bladder is very rarely necessary. 

Mr. John Bell in his principles of surgery expresses 
great indignation against such an operation as I have 
described. He says « if so rash a thing has been done, 
I protest against it as a sword put into the hands of a 
fool; such an instrument (a trochar-pointed catheter) 
would soon be in the hands of every young man, and 
would prove, what the crotchet is in midwifery, a merciless 
resource." If that excellent anatomist had only paused 
long enough to investigate the probable consequences of 
the operation, he could have convinced himself that 
no such terrible effects were to be dreaded, as his ima- 
gination, fruitful in the invention of horrors, lias antici- 
pated, and I am happy in the opportunity of attesting its 
perfect safety, at the same time that I would urge 
extreme caution in performing it. No one should under- 
take it who is not well acquainted with the anatomy of 
the parts. 

Mr. Bell censures with comparative mildness (if bis 
language can even be construed into censure) a much 
more dangerous expedient, that of forcing onward the 
catheter till it reaches the bladder. This operation is 
surely terrible. In Dr. Hunter's hands it proved fatal, 
and though Mr. Dease succeeded in some cases by this 
uncertain mode, it is one which no surgeon at the pre- 
sent day will venture to recommend. 

The introduction of the catheter in the female subject 
is an operation of no difficulty to a person acquainted 
*vith the anatomy of the parts. Before the operation the 



PLATE XIX. 




J.S&crsey- del XSeap. 




ELEMENTS OF SUIKiERY. 165 

room should be darkened, and from motives of delicacy 
every exposure should be carefully avoided. The ca- 
theter is to be held in one hand, and the fore linger of 
the other is to be placed upon the clitoris, from which a 
smooth surface extends backwards a small distance and 
terminates at the orifice of the urethra ; the finger passed 
along this smooth surface soon distinguishes the precise 
situation of this canal, and the catheter is then to be in- 
troduced and passed into the bladder. 

In the opposite plate are represented, 
Fig. 1. A straight canula and lancet for dividing the stric 
ture at or anterior to the bend of the urethra, 

2. A curved canula and lancet for the purpose of 

dividing the stricture when beyond the bend. 

3. The lancet separated from the canula. It is best 

to have it made with a thin wire stem, because 
it will be found to move more readily in the 
canula. 

4. Forceps for extracting calculi from tin; urethra. 



166 ELEMENTS OF SURGERY. 



CHAPTER XXII. 



Of Tapping the Bladder. 

This operation becomes necessary when all other 
means of evacuating the urine are found ineffectual. 

In itself it is by no means a dangerous operation, but 
it is very frequently followed by death, in consequence 
of being performed too late. Mr. John Bell remarks 
that in this case, as in strangulated hernia and lingering 
labours, delay is the greatest danger, and yet a remark 
which follows soon after is of equal importance, " the 
worst signs are no sure proofs of gangrene. In the most 
hopeless cases let the patient have his chance for life." 

Mr. Charles Bell considers the fourth day after a to- 
tal obstruction to the urine as the most favourable pe- 
riod for the operation. 

The bladder may be tapped from the perineum ; — above 
the pubes — and through the rectum. The difficulty of the 
first of these operations is considerable, and the extent 
of incision comparatively great. It has nearly gone into 
disuse, but I have been informed that it has lately been 
performed in London ; Mr. Astly Cooper plunges a lan- 
cet boldly into the bladder from the perineum, an ope- 
ration formerly performed by Dr. Jones of tiiis city. 

OF THE PUNCTURE ABOVE THE PUBES. 

In many cases of retention of the urine the bladder may 
be very distinctly felt rising nearly to the umbilicus. 
In such cases there is no danger of wounding the peri- 
toneum in puncturing above the pubes. 



ELEMENTS OF SURGERY. 167 

An incision is to be made with a scalpel about an 
inch in length, through the skin and fat which cover the 
lower part of the linea alba ; this incision should be 
made about half an inch above the pubis, and should 
extend between the pyramidal muscles down to the li- 
nea alba. A curved trochar (the curvature of which 
forms a segment of a circle seven inches in diameter) is 
now to be pifshed into the bladder, the stilet being with- 
drawn, and at the same time the canula pushed further 
inward, the urine will flow freely through it. The ca- 
nula is now to be fastened by tapes to a bandage passed 
round the body, care being taken to leave the orifice 
free, and to this should be adapted a plug of cedar, to 
be removed from time to time. A short catheter bent so 
as to fit the canula should be passed through it, in order 
to prevent the edges of the instrument from irritating the 
inner coat of the bladder. 

After a few days the adhesive inflammation will con- 
solidate into a perfect canal the aperture through which 
the canula has passed, and then the instrument being re- 
moved, an elastic catheter of the same diameter may be 
introduced, and changed once a week, as long as the 
circumstances of the case may require. 

The wound is to be healed whenever the natural pas- 
sage for the urine is sufficiently pervious. 

This operation I once performed in an old gentle- 
man in whom the urethra was completely obliterated, 
and the surgeons in attendance had no hope from the 
long duration of his disease and the great extent of the 
stricture, that he would ever evacuate the urine by the 
natural passage. He survived the operation several 
months during which time he was not much incommoded 
by the new method of making water. A fistulous orifice 
formed round the canula, and every drop of water was 
discharged through the instrument, the urethra remain- 
ing impervious. 



168 ELEMENTS OF SURGERY. 

Desault performed the operation frequently with suc- 
cess. 

OF PUNCTURING THE BLADDER THROUGH THE RECTUM 

The finger passed into the rectum readily comes in 
contact with the prostate gland, and immediately above 
this in cases of retention of urine the distended bladder 
is perceived lying nearly in contact with the rectum, a 
little cellular substance alone intervening between them ; 
at this place a curved trochar similar , to that used for 
the operation last described, can be easily introduced, 
upon the fore finger of the left hand. The posture of 
the patient when the operation is performed should be 
the same as in Lithotomy. 

This operation is very easy and very safe. The only 
caution necessary is to avoid the vesiculse seminales 
which is done by making the puncture considerably 
above the prostate gland, and exactly in the middle of 
the tumour formed by the distended bladder. The ca- 
nula should be left in the wound until the urine resumes 
its natural course, although in a case where it was acci- 
dentally removed very soon after the operation, no ill 
consequences followed. As the canula would prove ex- 
tremely inconvenient when the patient had an evacuation 
from his bowels, an elastic catheter could no doubt be 
substituted with advantage. 

In cases where the prostate gland is greatly enlarged or 
where the rectum is diseased, the puncture cannot be rea- 
dily made through the rectum and that above the pubes 
is to be preferred. The puncture through the rectum 
ought only to be performed where it is fairly presumed 
that the natural passage will ere long become pervious. 
An interesting case of the operation is related by Dr. 
Hamilton in the Philosophical Transactions, which proves 
its safety. Dr. Hamilton's patient speedily acquired the 



ELEMENTS OF SURGERY. 169 

power of discharging or retaining his urine at pleasure — 
a circumstance ascribed by Mr. John Bell and probably 
correctly, to the action of the levator ani muscle. The 
testimony of Mr. Home is favourable to this operation. 
He performed it in four cases. Mr. Charles Bell also 
recommends it. 

It is seldom necessary to puncture the bladder in fe- 
males. When, however, the operation is required, it 
can be very readily performed by passing a trochar 
through the vagina into the bladder, where it may be 
felt forming a large tumour. In case the obstruction in 
the urethra is permanent, the canula must be left in the 
bladder, and in that case it should be sufficiently long 
to project on the outside of the labia, where it is to be 
secured by means of a T bandage. 

In all cases in which it becomes necessary to leave 
a canula in the bladder it should be changed at least 
once in ten days, in order to remove the calculous mat- 
ter with which its extremity becomes encrusted. 



Voi. IT. 



170 ELEMENTS OF SUKGEIiV. 



CHAPTER XXIII. 



Of Stone in the Bladder. 

The urine in a healthy state contains the matter which 
when concreted forms a calculus, and all that seems ne- 
cessary for the formation of a stone in the bladder or 
kidney is the presence of a clot of blood, or some solid 
matter upon which this calculus may crystallize or conso- 
lidate — whether a nucleus of this kind is always neces- 
sary it is not easy nor important to ascertain. 

A stone in the bladder is perhaps as painful as any 
other disease to which the human body is liable, and it 
is sufficiently common to demand great attention from 
the student of surgery. 

Calculus generally forms in the kidney, and the symp- 
toms of stone commence with a pain in the loins, which 
becomes very acute upon motion, and is often followed 
by bloody urine, or urine resembling strong coffee in co- 
lour. The quantity is small and is sometimes totally 
suppressed. Efforts to vomit take place and the stone is 
commonly forced into the ureter, temporary relief is ex- 
perienced, but the symptoms soon return and continue 
until by degrees the ureter becomes dilated and affords 
a passage for the stone into the bladder. The warm 
bath, anodyne glysters, and the copious use of diluent 
drinks greatly facilitate the descent of the stone, and af- 
ford much n lief to the patient. 

When complete relief for a time is experienced after 
the preceding symptoms, there is great reason to believe 
that a calculus has been formed in the kidneys, and has 



ELEMENTS OF SURGERY. 17t 

descended into the bladder. It is of course small, and 
at this time the patient should be directed to drink freely 
of barley water, and when the bladder is distended with 
urine, to void it forcibly in a full stream, bending the 
body forward so as to render the neck of the bladder its 
most depending part. In this manner small calculi are 
sometimes discharged from the bladder, and much fu- 
ture suffering of the patient prevented ; but this termina- 
tion, in the male subject, is not very frequent, and more 
commonly the size of the stone gradually augments, and 
the symptoms of stone in the bladder are experienced, 
One of the most usual symptoms which attends through- 
out the whole course of the complaint, is an itching of 
the perineum and glans penis. In order to relieve this 
the patient pulls the prepuce, and this becomes, especial- 
ly in children, greatly elongated. Great difficulty [a 
experienced in making water ; the urine flowing in a 
full stream is suddenly interrupted by the stone falling 
over the neck of the bladder; and when the bladder is 
nearly emptied, violent pain is felt. The bladder is in- 
capable also of containing as much urine as in health. 
and desires to empty it are very frequent. Tenesmus 
frequently attends; pain is felt in voiding the stools, and 
a discharge of semen occasionally takes place when the 
bowels are evacuated. The mucus of the bladder is dis- 
charged with the urine in considerable quantity, and very 
frequently a sandy matter is mixed with it, the smell be- 
ing extremely fetid. A prolapsus ani occasionally takes 
place. Violent spasm of the bladder — dyspepsia — loss 
of appetite — diarrhsea, together with pain in various 
parts of the abdomen, often attend. The patient expe- 
riences an aggravation of these symptoms after exercise, 
or any irritating cause. A violent jolt is generally fol- 
lowed by bloody urine. Sometimes without any as- 
signable reason a very severe exacerbation of pain, 
and all the other symptoms come on. this is railed 



172 ELEMENTS OF SURGERY. 

of the stone and perhaps no sufferings transcend those 
experienced by a patient under such circumstances. 

The preceding symptoms seldom exist except the 
patient have actually a stone in the bladder, and yet as 
Bromfield remarks, " all together in the same subject 
they are not sufficient authority to perform the operation, 
unless the stone be first felt by the staff." Sir James 
Earle considers the least fallible sign to be the discharge 
of urine without pain, and violent pain after the bladder 
is emptied, arising from the contraction of the bladder 
upon the stone. 

The introduction of the sound however is never to be 
neglected when there is reason to suspect a stone in the 
bladder. The sound is a polished steel instrument, re- 
sembling a catheter in shape, but not like a catheter hol- 
lowed ; its point is also lower and straighter that it may 
touch every part of the bladder. - The method of intro- 
ducing it differs in nothing from the introduction of a ca- 
theter ; but in searching for a stone, the posture of a pa- 
tient and the shape of the sound may be varied greatly : 
if the stone be not found in one posture, another, and 
another must be tried. I have seen Dr. Physick in two 
cases succeed in detecting a stone with the* sound, by 
placing his patient nearly on his head, so that the fun- 
dus of the bladder became the most depending part. 

"When a difficulty of finding the stone exists, the blad- 
der should be examined in different states of fulness, and 
sometimes a silver catheter introduced has discovered a 
stone when it could not be felt with a sound, the urine 
in such cases flows through the catheter, the bladder 
contracts and forces the stone and the instrument in con- 
tact : the introduction of the finger into the anus often 
assists in finding the stone, and enables us to ascertain 
in some measure its size and form. When they come to- 
gether the sensation is not to be mistaken for any other, 
it may be distinctly felt and heard. 



ELEMENTS OF SURGERY. 173 

A stone once found, it will be useless to consume time 
in endeavours to dissolve it. The use of lithontriptic or 
as they are now more properly denominated, antilithic 
medicines are very serviceable in alleviating the symp- 
toms of stone, and in case of a severe paroxysm, opium, 
the warm bath, and blood letting, are useful. We are 
acquainted with a variety of medicines capable of dis- 
solving stone, when out of the body, but most of them 
are too irritating to be injected into the bladder. The 
gastric liquor of many animals possesses solvent powers 
in a very great degree, and dissolves among other articles, 
the urinary calculus. In my inaugural thesis published 
in 1802, are detailed some experiments which prove that 
this fluid may safely be injected into the bladder of a pa- 
tient with stone, and that portions of calculus are eva- 
cuated after such operations. It is to be feared, how- 
ever, that the accretion progresses almost as fast as the 
solution, and therefore unless some more powerful 
solvent can be injected, the operation is the only re- 
source. 

The most useful of the antilithic medicines, are, the 
various combinations of carbonic acid ; — the different al- 
kaline medicines; — magnesia; — and uva ursi. The 
mode of exhibiting these articles, may be found in the 
different dispensatories. That stones of considerable 
size have been dissolved occasionally by the use of these 
articles, I have no doubt, but that such an event is ex- 
tremely rare is most certain. I once dissected a gentle- 
man of this city who had been sounded some years be- 
fore he died, and a stone was evidently perceived, the 
sound of the staff striking on the stone was audibly dis- 
tinct. This gentleman's bladder contained no stone at the 
time of his decease. 

Without entering into a history of the operation of 
lithotomy which would occupy a volume, I shall pro- 



174 ELEMENTS OF SURGERY. 

ceed to describe the manner of performing the operation 
which I consider most advantageous.* 

The instruments necessary for performing the opera- 
tion, are, strong garters or bands for securing the pa- 
tients hands and feet, — a grooved staff or director, adap- 
ted to the urethra,— a scalpel,— a sharp pointed straight 
bistoury, — a gorget or knife for dividing the neck of the 
bladder, — forceps of various sizes for seizing and ex- 
tracting the stone, — scoops or levers of different degrees 
of curvature, — a sharp-pointed curved bistoury, for en- 
larging the wound in the bladder, if necessary, — strong 
forceps with a screw in the handle to break the stone if 
it be too large for extraction, — a glystering syringe and 
pipe, together with warm barley water, to wash out any 
fragments of stone, — sponges, warm water, needles, li- 
gatures, tenaculum, — a needle and curved forceps, for 
tying the pudic artery if it be cut, and warm olive oil 
for the purpose of lubricating the instruments.! 

All the instruments which the surgeon can possibly 
need should be at hand, and carefully put in order before 
the operation. The beak of the gorget should be adapt- 
ed to the groove of the staff, and should move readily in 
it. The gorget should have a perfectly keen edge, es- 
pecially at that part which commences the incision, which 
is the part immediately connected with the beak of the 
instrument. There is no method of having this part of 
the gorget perfectly keen, but by having the beak and 
blade separable, and Dr. Physick has accordingly for 
many years had his gorgets constructed in this manner. 



* A very excellent account of the various methods of extracting 1 si ones from 
the bladder, and a very good history of \he improvements which have been suc- 
cessively made in lithotomy may be found in the principles of surgery by 
John Bell, 2 vol. 

■\ I have not thought it necessary to represent in engraving, all these instru- 
ments as the most of them are familiar to every student of surgery. There are 
some however which it will be proper to delineate because they are not in gene- 
ral use. 



I'i. ATE -r.r 



FtytlSO.Vel M. 



Si 



t^ 














ELEMENTS OF SURGERY. 175 

As I consider this an object of primary importance to 
tike success of the operation, I shall describe the gorget 
of Dr. Physick which is represented in the adjoining 
plate.* 

Fig. 1. Gives a perspective view of the gorget; the 
blade a little open to shew in what manner it is connect 
ed to the stem and secured by the screw. 
«. The blade. 

b. The stem. 

c. The screw. 

d. The beak. 

p. The cutting edge. 
Fig. 2. The stem of the instrument comprehending 
♦he shaft, and beak. 

/. A groove gradually deepening to admit the point 

of the blade tig. 3. 
g. A perforation in the direction of, and to admit, 
the peg k, as a further security, and to pre- 
vent injuries to the point of the blade by the 
upper part of the groove b, 
h. The opening in the handle, admitting the blade. 
Fig, 3. A back view of the blade as relieved from 
the stem. 

2. The point. 
1c. The peg. 

I. The tutting edge, the curved line shewing the 
manner of grinding it away to form the edge. 
m. The female screw. 
Fig. 1. A section of the gorget of a proper size, de- 
scribing the angle formed by uniting the blade and stem. 
Figs. 5, 6, 7, 8, 9, 10, represent six blades, of various 
sizes, adapted to one common beak, whereby the sur- 
geon is furnished with a gorget proper for patients of 

• This instrument is extremely will made by Mr. Bishop, from Savig-nys 
manufactory, London, who published a description of it in Coxe's .Medical Ma- 
, in 1804. 



176 ELEMENTS OF SURGERY. 

every age, and at an expense not exceeding one fourth 
the price of a set of common gorgets. 

The size and angle of the blade and haft of the in- 
strument should be similar to those of the common gor- 
get. The length from the beak to the angle four and a 
half inches ; the handle four inches long. The drawing 
represents the instrument on a smaller scale. The width 
of the cutting edges in figures 5, 6, 7, 8, 9, 10, are ac- 
curately copied from Dr. Physick's instruments. 

Dr. Physick has had a similar gorget constructed with 
a double blade, but there are very few occasions where 
the stone is so large as to require its use. 

The patient about to submit to lithotomy should if 
practicable choose the spring or autumn in preference to 
the cold or hot months. The operation should never be 
performed during a paroxysm of stone. A temperate 
diet should be directed for some time previously, and if 
plethoric the patient should be bled. It is well to ad- 
minister, on the day preceding the operation, a dose of 
castor oil, and to empty the rectum two hours before the 
appointed time by an injection. The perineum should be 
shaved, after which an cenema of laudanum and water 
may be administered, an hour or more before the opera- 
tion, or what is equivalent a few grains of solid opium 
may be introduced into the rectum, and the patient 
should void no urine for several hours before the time 
affixed for operating. 

OPERATION. 

The patient is to be placed on the end of a common 
dining table, with the leaves down, covered with blan- 
kets. The staff is to be well oiled and introduced ; the 
different surgeons present take hold of it and satisfy 
themselves that they feel the stone. A strong fillet or 
garter is fastened by means of a noose, round each wrist, 



ELEMENTS OF SURGERY. 177 

the patient is directed to grasp his feet with his hands, 
and by means of the iillets they are securely bound to 
gether. 

The patient is now placed close upon the edge of the 
table, his head and back being supported by pillows in 
such a manner as to present the perineum in a conve- 
nient manner to the operator. In this posture he is to 
be held by two assistants who stand along side of the ta- 
ble (which of course should be narrow) and place the 
knees of the patient in their armpits, separating his limbs 
and firmly holding his feet. 

Another assistant takes hold of the staff with one hand 
and with the other raises the scrotum so as to expose the 
perineum. He is to hold the staff in such a manner that 
it may project a little towards the left side of the peri- 
neum. The usual attempts to make its convexity very 
prominent, are however, attended with risk of forcing the 
staff out of the bladder, and there is no advantage in it, 
because the first incision should be made without any re- 
ference to the staff*. 

The surgeon being seated conveniently, commences the 
first incision with a scalpel, the point of which he inserts 
through the skin, at that part of thci perineum which is im- 
mediately opposite the lower end of the arch of the pubis, 
of course the incision begins at the raphe of the perineum 
just behind the scrotum ; the knife is to be carried stea- 
dily in a right line terminating midway between the 
lower margin of the anus and the tuberosity of the is- 
chium of the left side. The first incision should be 
deeper than it is commonly made, as there is no danger 
to be dreaded at this stage of the operation, except a 
wound of the rectum which is easily avoided. This in- 
cision in an adult should be between three and four 
inches in length. By two or three successive strokes of 
the knife the incision is to be deepened, and the trans- 
versales perinei muscles completely divided— when this 
Vol. U. V a 



178 ELEMENTS OF SURGERY. 

is done the groove of the staff is very readily felt, and 
the prostate gland at the bottom of the wound. The sur- 
geon now exchanges his scalpel for a sharp straight 
bistoury the point of which he inserts with the back to- 
wards the rectum into the membranous part of the ure- 
thra ; with this instrument he slits up the membranous 
part of the urethra by cutting in the groove of the 
staff from the prostate gland to the bulb and effects 
in this manner by one stroke of the knife what I have 
known surgeons half an hour in accomplishing by re- 
peated attempts to dissect down to the staff with a scal- 
pel.* It is of no consequence whether the bulb be 
cut or not by this incision, it is unnecessary to do it,, 
unless the surgeon should have difficulty in seeing or feel- 
ing the groove of the staff, and in that case, no danger 
attends his slitting the urethra freely forwards, always, 
however, cutting from the staff, the point of the bistoury 
being in its groove. The division of the urethra is great- 
ly facilitated by the use of the bistoury, and one simple 
incision is made instead of twenty. The staff is now 
laid bare to a considerable extent, and is generally visi- 
ble, but is always readily felt by the surgeon's finger ; it 
only remains now to divide the prostate gland and neck 
of the bladder, which may be readily effected by a bis- 
toury, scalpel, or gorget, but far most conveniently by 
the last named instrument. The surgeon therefore after 
laying bare the staff places the nail of the left index fin- 
ger in the groove of the staff and introduces the beak of 
his gorget previously dipped in warm oil, into the situa- 
tion where his nail had been, and now rising from his 
chair he takes the handle of the staff in his left hand 
and moves the beak in its groove, ascertaining that no 
membrane or other substance intervenes between the 
staff and beak of the gorget. He should be certain also 

* This direction is not always necessary t& be observed, as the staff is oft? r 
exposed very readily by means of the scalpel. 



ELEMENTS GF SURGERY. 179 

at this moment that the staff has not slipped out of the 
bladder. With a gentle steady motion he passes the 
gorget along the groove of the staif into the bladder, de- 
pressing the handle of the gorget in such a manner that 
the beak may move along the convex part of the staff 
nearly at a right angle, and the beak of the gorget will 
consequently take a direction nearly in a line from the 
anus to the umbilicus. In introducing the gorget Dr. 
Physick recommends to push the staff and gorget as far 
towards the right side of the perineum as possible, in or- 
der to avoid wounding the pudic artery. The urine 
gushing from the bladder and flowing along the gorget 
announces the division of the neck of the bladder. The 
gorget is instantly removed (and there is no risk of ma- 
king a wound in withdrawing it unless by great care- 
lessness) and the fore finger of the left hand introduced and 
brought iu contact with the stone. The staff may now 
be taken out, and the forceps introduced, or if the sur- 
geon have any fears from the smallness of his opening 
into the bladder, that he will not readily find the passage, 
he may leave the staff* in as a guide for the forceps, but 
lliis ought never to he necessary* When the forceps 
dipped in warm oil are introduced, the surgeon should 
touch the stone before he opens them, and then with one 
handle iu each hand he separates the blades and grasps 
the stone. It is best to use small forceps at first as they 
enter more easily, and in general, answer as well as the 
large ones. 

This part of the operation is sometimes very embar- 
rassing. Surgeons have been baffled in their attempts 
to find a stone with the forceps which with the staff they 
could readily touch, and sometimes an hour has been 
consumed in fruitless searches for the calculus. In ge- 
neral the most depending part of the bladder contains 
the stone, and this is commonly immediately on tbe rec- 
tum, or a little to one or the other side of it ? the elevation 



180 ELEMENTS OF SURGERY. 

of the handles of the forceps, therefore commonly brings 
them in contact with the stone. The introduction of a 
finger into the rectum frequently facilitates very much 
this part of the operation. In some cases the stone is 
situated near the fundus of the Madder ; in these cases 
a scoop may be used to draw it towards the wound in 
the bladder. In all cases of difficulty in finding the 
stone, it is better to search with a finger or a female ca- 
theter, than with the forceps. The bladder is often fill- 
ed with clotted blood, this should be rinsed out with 
warm barley water if it prevent the extraction of the 
stone. 

The surgeon having grasped the stone with his for- 
ceps, should be careful that he has taken hold of it iu the 
shortest diameter so that it may occasion as little lacera- 
tion as possible whilst it is extracted. The use of a 
simple lever which is contained in all lithotomy cases, 
assists greatly in placing the stone in a position conve- 
nient for extraction. When this is done a regular bttt 
forcible effort is to be made and the stone extracted. 
The extraction may often be facilitated greatly by mov- 
ing the forceps from side to side, using in this manner 
each blade as a lever. It sometimes breaks in the grasp 
of the forceps, ar.-d then the larger fragments are to be 
successively taken out by the forceps, the smaller ones 
by means pf a scoop, and the detached sandy matter is 
to be washed out by injecting forcibly a stream of warm 
barley water into the bladder, which will be evacuated 
through the wound, pleno rivo, and with it all the smaller 
particles of calculus. 

Sometimes the stone is too large to be extracted, and 
then it is to be broken, by means of a strong pair of for- 
ceps with a screw in the handles, and the pieces extract- 
ed as we have just directed, but if a small enlargement 
of the wound in the neck of the bladder will enable the 
surgeon to effect the extraction without recourse to this 



ELEMENTS OF SURGERY. 181 

expedient, it will be better to introduce the index finger 
of the left hand into the bladder, and then a curved bis- 
toury with a sharp point may be used in such a manner 
as to enlarge the wound, the surgeon cutting down upon 
his finger, runs no risk of wounding any important part, 
the prostrate gland may be thus divided with great facili- 
ty to any necessary extent, and the extraction of a very 
large stone may in this manner, in general, be conveni- 
ently effected. The surgeon should always remember, 
that it is better to cut than to tear, and the maxim of 
Celsus should never be forgotten " plaga, paulo major 
quam calculus sit." 

The surgeon should next examine if any other stone 
remains. If the stone have a rough surface it is general- 
ly considered a proof that no other remains, the finger 
however or a female catheter should be introduced for 
the purpose of ascertaining this fact. 

One of the chief subjects now demanding attention i< 
the hemorrhage. It always happens that some consi 
derable blood vessels are divided and bleed freely in this 
operation. The arteria transversalis perinei is always 
cut, as it runs directly across the perineum in the course 
of the incision. This artery is easily secured with a li- 
gature if it bleed freely, but commonly it stops after the 
operation is completed. 

The artery of the bull) of the urethra is occasionally 
divided, and sometimes it is necessary to tie it up, but 
the chief danger arises from the pudica interna, a very 
large artery running along the ramus of the ischium which 
is sometimes wounded by the edge of the gorget. When 
this happens the hemorrhage is profuse, and in many ca 
ses has proved fatal. I am happy in being able to de- 
scribe a method of securing this vessel which obviates in 
great measure this danger from lithotomy. 

In the year 1791, although a boy, I had the honour 
of assisting j)r. Physick in his first operation for stone. 



182 ELEMENTS OF SURGERY. 

and it happened that in passing the gorget he divided 
the pudic artery. He immediately placed a finger upon 
the spot, the bleeding ceased, and he felt distinctly the 
trunk of the vessel pulsating between his finger and the 
ramus of the ischium. It was evident that if the flesh 
between his finger and the bone could be compressed, 
the hemorrhage would be commanded. He accordingly 
passed a tenaculum under the trunk of the artery, the 
point of which came out near the bottom of the wound. 
A strong ligature was then passed under the projecting 
point and handle of the tenaculum, and was firmly tied, 
it included consequently a portion of flesh, in which the 
wounded artery was contained, and effectually stopped 
the bleeding. This measure, which was contrived and 
executed in as short a time as I have consumed in de- 
scribing it, can no doubt be applied in similar cases with 
equal advantage : the opposite plate Fig. 1, conveys an 
idea of the manner in which this was effected. Another 
mode however which promises to be more easily exe- 
cuted, consists in passing an armed needle contained 
in a curved forceps (Fig. 2) under the artery, bringing 
it out near the bottom of the wound and then tying 
the ligature. This operation I have never seen per- 
formed, but have no doubt that it could easily be 
done. 

After the operation is completed, the patient is to be 
placed on his side, on a mattress, without any dressing 
to the wound, a folded sheet being laid under him in 
such a manner, that as fast as it becomes wet by the 
urine, a dry part may be substituted, and to prepare 
the mattress, a piece of waxed linen may be placed 
under the sheet. A low diet and rest are the only reme- 
dies necessary. 

In some cases the patient has no unpleasant symptom 
in consequence of the operation, and in other instances 
death results without any evident cause. Mr. Charles 



Fi.a it: xxi. 




fWr 



% 










ELEMENTS OF SURGERY. 183 

Bell says he has known « the violence of the operation, 
without hemorrhagy or inflammation, to kill the patient 
in about ten hours." I have seen patients die in three 
or four days without inflammation. Sometimes gangrene 
results from the escape of urine into the surrounding cel- 
lular texture, and sometimes the bladder inflames violent- 
ly and death results from this cause. Peritoneal inflam- 
mation in some instances comes on, terminating very 
speedily in death. In cases where inflammation runs 
high, bleeding, and evacuating remedies are to be used 
and large blisters are to be applied over the abdomen. 

In general the urine flows for the first few days after 
the operation through the wound, but in two instances 
in which I performed lithotomy it was my good fortune 
to witness the healing of the neck of the bladder by 
the first intention. In the first case (which occurred in 
private practice) not one drop of urine ever flowed 
through the wound after the operation was completed, 
a circumstance which I ascribed to the smallness of the 
stone, and the consequent absence of contusion. This 
patient walked about in two weeks, and his wound was 
healed before three weeks had elapsed. The other 
case occurred in the Pennsylvania hospital, the stone 
was much larger, and it required great force to extract 
it. The urine in this patient flowed during the after- 
noon and evening of the day on which I operated, 
through the Wound, but never again, and the wound 
healed as if in one of the limbs.* I have no hesitation 
in ascribing the successful termination of these cases to 
the use of a gorget which is so perfectly keen, as to pass 
without any resistance through the prostate gland and 
neck of the bladder. 

I have purposely avoided noticing the various modes 

* Copcland in a note contained in his work on the rectum, mentions a case 
trhere the wound made in lithotomy healed by the first intention. Dr. Physick 
met with similar succi 



184 ELEMENTS OF SURGERY. 

of operating, now in use in Europe. The knife has 
many advocates, and the lithotome cache some. I have 
seen a very celebrated surgeon in Paris, cut off an arm ; 
cut out an eye, and perforin lithotomy with the same 
bistourie, but I confess this simplification of apparatus 
is carried farther than I approve, and since I am per- 
suaded that most of the objections to the gorget have ori- 
ginated from the use of bad gorgets, I have no hesita- 
tion in recommending a sharp gorget as the most con- 
venient knife with which the bladder can be opened in 
lithotomy. 

An operation called nephrotomy has been proposed 
for the extraction of stones from the kidney. It consists 
in making an incision through the integuments and mus- 
cles immediately over that gland, and afterwards expos- 
ing and opening the pelvis of the kidney, sufficiently to 
allow the extraction of the stone. 

This operation has never I believe been performed, and 
probably never ought to be. It is in almost every in- 
stance doubtful, whether there exists a stone in the kid- 
ney, because every symptom resulting from such a cause 
occasionally occurs, when there is no reason to believe 
the existence of a calculus, and on the other hand where 
these symptoms have been ascribed with great probability 
to that cause, a speedy and permanent relief has been 
obtained without recourse to an operation : — circum- 
stances which render the performance of so dangerous 
an operation highly unwarrantable. 

There is however one case in which it would be pro 
per to make an incision in the vicinity of the kidney for the 
extraction of a stone, and that is when suppuration has 
taken place, and an abscess has formed ; as soon as the 
tumour becomes prominent it would be practicable and 
safe to make an incision into it, and extract the stone. 
The great blood-vessels being in this case anterior to the 
abscess would not be endangered. 



ELEMENTS OF SURGERY. 185 

The operation of lithotomy in the female, consists in 
simply enlarging the urethra, laterally by means of a 
scalpel or gorget, and a short straight director or staff. 
It may also be done by cutting through the vagina upon 
the staff, but incontinence of urine is apt to follow ; as 
it does indeed in some cases after the former operation. 
Lithotomy in the female, is an operation of no more 
difficulty, than the dilating of a sinus with a scalpel and 
director. Indeed it may often be done with sponge tent, 
and many cases of success by this plan are recorded. 



Vol. II. B fj 



186 ELEMENTS OF SURGERY. 

CHAPTER XXIV 

Of Fistula in Ano. 

When abscesses form in the vicinity of the anus, they 
are generally very difficult to be healed, and become fis- 
tulous. 

The complaint generally commences with a phlegmo- 
nous tumour near the anus, attended with considerable 
pain and hardness. In this stage it is often mistaken for 
a hemorrhoidal affection, and this mistake prevents the 
application of the necessary remedies. The tumour ad- 
vances gradually to suppuration, and matter is formed. 
In some cases the disease proceeds thus far with but 
little pain, and I have known a patient with fistula, utterly 
ignorant of the time when the disease formed. In other 
instances it is attended with extreme pain : with great 
swelling, and with extensive suppuration, with disury 
and even suppression of urine from the pressure of the 
tumour upon the neck of the bladder or the urethra. 

Fistula in ano sometimes results from an erysipelatous 
affection of the nates, and in these cases the disease is 
generally extensive, in consequence of the mortification 
which takes place in the surrounding cellular texture. 
I have also known a psoas abscess to point near the but- 
tock, and when opened more than a gallon of pus was 
evacuated. The patient recovered and the upper part 
of the abscess healed, but a fistula formed which requir- 
ed a surgical operation. I have witnessed so many ca- 
ses of fistula, in patients affected with pulmonary con- 
sumption, that I am disposed to consider it, frequently 
symptomatic of that disease. In all the instances I have 



ELEMENTS OF SURGERY. 187 

met with, the patient has died soon after the healing of 
the fistula. 

TREATMENT. 

The treatment of the disease depends upon the stage 
at which the surgeon is called. Should he be sent for 
before suppuration has taken place, the usual remedies 
for inflammation are to be prescribed, with a view of pre- 
venting it. I shall not detail them, but simply remark 
that leeches in addition to the other evacuations are of 
great use in the present case, fifty or sixty may safely be 
applied to an adult, with an inflammatory tumour near 
the anus. Nothing is more ridiculous than the manner 
in which leeching is directed by the British surgeons ; 
they speak of a leech, or two, as beneficial. To obtain 
advantage from leeches, in cases like the present, from 
eight to sixteen ounces of blood should he drawn by 
them, and this quantity can only be evacuated from an 
inflamed part by applying from twenty to sixty leeches. 

If the surgeon be called after suppuration has taken 
place, or if notwithstanding his exertions the abscess 
point externally, it should be opened early with a lancet 
in order to prevent an extension of the disease by ulce- 
ration. When this is done, a poultice is to be applied, 
and a free discharge of matter takes place, after which 
the abscess sometimes (though rarely) heals, as in any 
other place. More commonly the sore remains open, 
discharging matter by an aperture near the anus, and 
a fistulous sinus forms. The disease in this state has no 
communication with the rectum, and is called an incom- 
plete fistula. In some cases beside the external open- 
ing, another is formed into the rectum, and a probe pass- 
ed by the external aperture comes in contact with a fin- 
ger in the rectum, this constitutes a complete fistula, 
from which flatus and faeces mixed with pus are often 



188 ELEMENTS OF SURGERY. 

discharged. An occult fistula is that in which the 
abscess opens into the rectum, but not externally ; an 
event which sometimes happens. 

The treatment of all these cases consists in laying 
open the fistulous ulcer in such a manner that the rectum 
and the fistula may form one cavity, with a free external 
aperture. The mode of performing the operation is to 
place the patient bending over a table, the nates being 
separated by an assistant. The depth and course of the 
sinus being previously ascertained by careful examina- 
tion with a probe, the surgeon passes the index finger 
of his left hand, well oiled, into the rectum, and a narrow 
curved bistoury down to the very extremity of the sinus. 
If the fistula be complete, his bistoury and finger will 
come in contact, and they are to be drawn out together 
in such a manner as to divide the rectum from one end 
of the fistulous ulcer to the other. If the fistula be in- 
complete, a hole must be made through the rectum, by 
means of the bistoury, and the operation finished in the 
same manner. In the former case a blunt pointed or 
probe-pointed bistoury answers best ; in the latter it is 
necessary to have the point of the instrument sharp, to 
puncture the rectum. Dr. Physick has constructed a 
bistoury, which combines, to a certain extent, the advan- 
tages of the blunt and sharp pointed bistouries, and pos- 
sesses some advantages over both. The annexed plate 
represents this instrument. 

Fig. 1, The instrument in the handle half open. 

Fig. 2. The silver guard, a. a. a small button on each 
side of the guard to relieve it from the blade. 

b. A notch or slit in the guard which slides upon the 
screw c, to secure it upon the blade. 

Fig. 3 and 4. The extremities of the blade and of the 
guard to shew the manner of their conuexion. 

When the instrument is furnished with the guard it 
resembles a probe, and may be passed down to the hot- 



Plate xxu. 



Guarded J3istoury 




ELEMENTS OF SURGERY. 189 

torn of the sinus, and by pressing forward slightly the 
guard it is detached, and the naked blade remains very 
nearly in the same spot where the probe had been. The 
guard defends the sinus from all the irritation which re- 
sults from the sharp edge of the common bistoury. This 
instrument combines all the advantages of the probe 
pointed and sharp pointed bistouries except one, which 
is that the sharpness of the point when the guard is de- 
tached, is apt to prick the surgeon's finger in the rectum, 
an inconvenience which it possesses in common with 
the sharp pointed bistoury, and which can only be 
obviated by defending the end of the finger. This may 
be done with a piece of thin lead, or a common thimble 
secured by a string fastened to the wrist. I have often 
used the instrument, however, and have preferred the 
trifling puncture to the trouble and inconvenience of the 
thimble. The bistoury is extremely convenient for open- 
ing other sinuses, for dividing the prepuce in cases *of 
phymosis, and for many similar surgical purposes. A 
variety of guarded bistouries have been contrived. I 
think this the simplest aud best. 

After the operation, a dossil of lint should be intro- 
duced between the edges of the wound from one end of 
the incision to the other, in order to prevent the reunion 
of the cut surfaces. After the first dressings come away 
either with a stool, or by suppuration, light dressings of 
lint are to be applied. 

When several sinuses exist they are to be treated in 
the same manner, and laid open into the rectum. 

In cases of occult fistula the surgeon can commonly 
perceive a tumour formed by the collection of pus, or fae- 
ces in the sinus, and this he opens externally with a lan- 
cet, after which the treatment is similar to that of a com- 
plete fistula. But I have seen a kind of occult fistula, 
formed just within the verge of the anus, and seated un- 
der the skin at this place, which discharges pus andoc- 



190 ELEMENTS OF SURGERY. 

casions much irritation ; in this case the sinus is to be 
sought by means of a bent probe, and the whole sac is to 
be removed with scissors. I have seen several cases of 
this disease, and all have been cured in this manner. 

There are some cases of fistula in which the sinus ex- 
tends beyond the reach of the finger, and other cases in 
which arteries of considerable size are situated in such a 
manner as to be wounded by the common operation. In 
such cases it has been the practice of Desault, in which 
he has been followed by other surgeons, to pass a leaden 
wire through the fistula and out at the anus. This wire 
is to be twisted from time to time in such a manner as to 
compress the part of the rectum usually divided by the 
bistoury, so as to occasion ulceration and an absorption 
of the part. In this way the sinus gradually heals above 
the leaden wire, and by the time the parts are ulcerated 
through, the cure is nearly completed. When the fistula 
is complete, a perforation must be made through the 
rectum by means of a stilet adapted to the canal, which 
is to be received upon a piece of wood introduced into 
the anus, after which the wire passed through is to be 
drawn down by forceps ; for a more particular account 
of this mode of treatment I refer to Desault' s posthumous 
works published by Bichat. 

It often accelerates the cure to commence it by De- 
sault' s plan, and after the wire has acted long enough to 
bring the sinus down within the reach of the bistoury, to 
divide it with this instrument. 



ELEMENTS OF SURGERY. 191 



CHAPTER XXV. 

Of Hemorrhoids. 

A varicose or preternaturally distended state of the 
veins in the vicinity of the anus constitutes the dis- 
ease called Piles or Hemorrhoids. In some chronic 
cases the tumour appears to consist of a solid fleshy 
mass without any enlarged blood-vessels. A patient af- 
flicted with this disease is subject to copious discharges 
of blood from a rupture of the veins whilst evacuating 
his bowels, and fatal hemorrhage has occasionally re- 
sulted. The founder of the Arian heresy, and the phi- 
losopher Copernicus, are celebrated characters said to 
have perished in this manner. The inconveniences at- 
tending the complaint are often extremely great and a 
variety of dyspeptic symptoms are occasioned. Extreme 
pain is experienced in going to stool, followed by violent 
tenesmus, by profuse bleedings, aud by a prolapsus ani, 
or descent of a large mass of hemorrhoidal tumours, 
which sometimes remain obstinately enlarged and irre- 
ducible. 

The tumours are generally internal and are covered 
by the lining membrane of the rectum, but sometimes 
external tumours exist formed of the common integu- 
ments. 

The disease is peculiarly frequent in sedentary men. 
whose digestion is impaired, and it also occurs in others 
of costive or irregular habits of body. Pregnancy, en- 
larged abdominal viscera, and other circumstances which 
interrupt the circulation of blood through the bowels are 
frequent causes of hemorrhoids. 



192 ELEMENTS OF SURGERY. 

At times the symptoms are mild, and at other periods 
they are greatly aggravated. An attack of piles is gene- 
rally treated by bleeding, laxative medicines, leeches, 
and cold and astringent applications to the part ; when 
the tumour remains externally, and is constricted by the 
sphincter ani, leeches and cold applications are extreme- 
ly useful, and a variety of astringent lotions and oint- 
ments have been contrived for the purpose of affording 
relief. Those which I prefer, are the common ointment 
prepared by mixing very finely powdered galls with 
hog's lard, and another ointment formed of white lead 
mixed into a paste with laudanum, and then incorporated 
with simple cerate. The ingredients of this ointment, 
though they by no means form a neat chemical compound, 
can yet be sufficiently well combined for use, and they 
form a very comforting application to the part. 

A radical cure, however, should always be attempted 
by extirpating the hemorrhoidal tumours, either with a 
ligature or knife. Mr. Abernethy has of late highly 
commended the latter, as an operation equally safe and 
much less painful than the former, but the accidents 
which have resulted from wounds of the hemorrhoidal 
veins induce me to prefer very decidedly the ligature. It 
is unquestionably painful, but is safe and certain. The 
operation consists in affixing a strong ligature upon the 
protruded tumour, whilst the patient strains as if at stool 
in order to propel them as much as possible. A parti- 
cular description of such an operation is unnecessary. 
The ouly cautions I would urge, are to tie only one tu- 
mour at a time, and to tie it so firmly as to intercept 
completely all circulation, so that the part may mortify 
and drop oil*. A low diet should be observed, and if 
great pain result from the operation opium should be ad- 
ministered. The best local application is a cold poul- 
tice supported by a T bandage. When the tumour falls 
off a second can be tied, and all may be thus removed 



ELEMENTS OF SURGERY. 193 

in succession. Where the base of the tumour is too 
large to admit the application of a ligature, a needle 
armed with a double ligature must be passed through its 
base, and one string tied round each half of the tu- 
mour. 

Mr. Ware thinks it unnecessary in general to remove 
all the hemorrhoidal tumours, he believes the pain to 
proceed chiefly from one or two more inflamed and irri- 
table than the rest, but smaller and less prominent, pro- 
truding just low enough to be compressed by the spine- 
ter muscle. , He advises the removal of these hardened, 
inflamed, painful tumours by means of a hook and scis- 
sors, and supposes that those which remain will collapse 
and disappear. This practice, however, is by no means 
safe, and Mr. Petit records an instance of fatal hemor- 
rhage from cutting off some internal hemorrhoids. The 
only hemorrhoidal tumours which 1 think it safe to cut 
off, are those which are completely external, and these 
should always be removed by the knife. 



Vol. II C 



194 ELEMENTS OF SURGERY. 



CHAPTER XXVI. 



Of Prvhqmis Ani. 

A protrusion of a portion of the rectum, or of its in- 
ternal coat, out of the anus, is denominated a prolapsus, 
or procidentia ani. In some cases a considerable por- 
tion of the intestine protrudes in this manner. 

The causes of the complaint are such as tend to weak- 
en the action of the muscles which support the intestine, 
and the violent exertions of the rectum in consequence of 
certain irritations. The frequent use of cathartics, es- 
pecially those which contain aloes, — the presence of as- 
carides in the lower part of the alimentary canal, — habi- 
tual costiveness, and hemorrhoids, have all occasionally 
produced prolapsus ani. I have known it a consequence 
of the tenesmus attending dysentery. 

In some instances the intestine remains a considerable 
length of time unreduced without any ill consequences, 
but more commonly it swells and inilames very speedily. 
It is therefore right to attempt as soon as possible the re- 
duction of the prolapsed part, and this can be best done 
with the fingers of the surgeon, the patient being placed 
on his back with the nates elevated. 

If the surgeon however be not called until the protrud- 
ed intestine is swollen and inilamed, the attempt at re- 
duction will be abortive ; in which case the usual re- 
medics for inflammation are to be employed. Bleeding, 
general and local, here become necessary. Leeches are 
to be applied to the swelling, after bleeding from the 
arm, and a soft poultice with lead water is to be applied 
to the part. The bowels if disordered are to be compos 



ELEMENTS OF SURGERY. 195 

ed by opium. By these means the protruded rectum 
may in general be replaced, but the complaint is unfor- 
tunately very apt to return, and the chief difficulty is to 
prevent its recurrence. 

Numerous bandages and machines have been contrived 
for this purpose ; one of the most ingenious is that of Mr. 
Bernard of Paris, who has constructed of the same mate- 
rials as those which form the elastic catheters, a perforated 
pessary, which when introduced within the sphincter ani, 
prevents the prolapsus of the intestine, and permits the 
evacuation of the faeces. This instrument should be in- 
troduced after the reduction of the protruded gut, and 
kept in its situation until the irritation occasioning the 
prolapsus shall have subsided, after which it may be re- 
moved ; the softness of its texture, the smoothness of its 
surface, its elasticity and lightness, prevent it from giv- 
ing much irritation. I have never had an opportunity of 
trying this instrument. To affect a permanent cure, the 
use of tonic and astringent remedies becomes necessary, 
and a careful abstinence from all those circumstances 
which produce the complaint. 

Dr. Physick has succeeded in some cases in complete- 
ly curing prolapsus ani, by confining his patients exclu- 
sively to a diet of rye mush and sugar, and the same re- 
medy has proved equally beneficial in the hands of 
other practitioners. 

During the use of such a diet, the bulk of the abdomen 
becomes considerably diminished, the bowels are kept 
constantly in a state somewhat loose, and all the faeces 
which are evacuated are of very soft consistence, cir- 
cumstances which combine to lessen the eifort of the ab- 
dominal muscles, and thereby to prevent the bowel from 
being protruded with the faeces. 

Cases are recorded in which large portions of the ali- 
mentary canal have protruded at the anus. In the Me- 
moirs of the French Academy, the case of a chil4 is 



196 ELEMENTS OF SURGERY. 

related in whom a complete eversion of the colon took 
place ; it began eleven inches from the anus, and termi- 
nated five or six inches outside of it. The eversion ap- 
peared to commence at the ccecum, and passed through 
the whole tract of the rectum. Other cases nearly simi- 
lar have occurred. These however are instances of in- 
tus-susceptio, in an inordinate degree, and probably ad- 
mit of no cure. 

Prolapsus ani is most frequent in children, but some- 
times occurs in adults. Mr. Hey has in some cases re- 
moved by the knife the pendulous portion of the rectum, 
and has in this manner effected a cure. The operation 
is however a severe one, and I would therefore recom- 
mend a long continued trial of Dr. Physick's method, 
before it is resorted to. Should this prove as successful 
in grown persons, as it has hitherto in children, there 
will be no necessity for so serious an operation as that 
performed by Mr. Hey* 

Where prolapsus ani is produced by hemorrhoidal 
tumours, these ought certainly to be removed in the man- 
ner already directed. 



ELEMENTS OF SURGERY. 197 



CHAPTER XXVII. 



Of Aneurism. 

An aneurism is a morbid dilatation of an artery. This- 
^definition does not however, include a species of aneu- 
rism denominated spurious or false, which arises from 
a wound or rupture of an artery whereby a cavity con- 
taining arterial blood is formed in the cellular texture 
surrounding the vessel* 

This general division of aneurisms into true and false, 
has been unnecessarily complicated by subdivisions, 
which I shall not here enumerate, but shall describe in 
succession such varieties as are important to be known. 

It was formerly a current opinion that whenever the 
coats of an artery became weakened at a particular spot, 
the usual force of circulation would dilate into an aneu- 
rism the debilitated vessel, and Dr. William Hunter 
imagined that if the external coats of an artery were cut 
through, the inner coat might be protruded and gradual- 
ly dilating become an aneurismal tumour. This erro- 
neous theory has, however, been completely subverted 
by the experiments of Mr. J. Hunter and Mr. Home, 
who dissected off the outer coats and adventitious sup- 
port of an artery, and the internal coat alone being left, 
was found sufficient to continue the circulation without 
acquiring any increase of volume at the injured part. To 
prevent any accession of strength to the denuded vessel, 
it was prevented from contracting adhesions to the sur- 
rounding substance. The experiments therefore prove 
that aneurism does not depend upon simple debility of 
an arterial trunk. 



198 ELEMENTS OF SURGERY. 

Within a few years professor Scarpa has published a 
very interesting volume on aneurism, and has attempted 
to refute the received opinions respecting the nature of 
the disease, and to substitute in their room a doctrine of 
his own. He boldly declares, that all aneurisms arise 
from a wound or rupture of the inner coat of an artery, 
and consequently, that no such disease as true aneurism 
is to be found. The opinion of the learned professor, is 
delivered with nn air of confidence, extremely imposing, 
and many surgeons have adopted it. t< I have ascertain- 
ed (says Scarpa) in the most certain and unequivocal 
wanner that there is only one kind or form of this dis- 
ease, viz. that formed by a solution of continuity or rup- 
ture of the proper coats of the artery with effusions of 
blood into the surrounding cellular substance, which so- 
lution of continuity is occasioned sometimes by a wound, 
a steatomatous earthy defeneration , a corroding ulcer, or 
a rupture of the proper coats (the internal and muscular) 
of the artery without the concurrence of a preternatural 
dilatation of these coats being essential to the formation 
of this disease, and therefore that every aneurism, wheth- 
er it be internal or external, circumscribed or diffused, is 
always formed by effusion." 

The only argument advanced by Scarpa in defence of 
Ms novel opinion, is, the result of his individual observa- 
tions ; a very slender foundation certainly, upon which 
to ground so strong a conclusion. At most the dissections 
of the industrious anatomist only give a colour of plausi- 
bility to his doctrine, and by no means establish its cor- 
rectness. After a very attentive examination of his cases 
and his remarks, I shall venture to record my total dis- 
sent from his opinion, which I cannot but believe to have 
originated in very imperfect views of the physiology and 
pathology of the absorbent system. 

From Scarpa's dissections, from the observations of 
other anatomists, and from the dissections I have myself 



ELEMENTS OF SURGERY. 199 

made and witnessed, I have no doubt that aneurism is a 
disease seated in the proper coats of an artery, and that 
this disease speedily produces a change in the structure of 
the artery, generally, though not always attended by an 
enlargement at the diseased spot. The nature of the 
change 1 do not profess accurately to comprehend, but 
Mr. Hunter has proved that it precedes the dilatation of 
the vessel. I have a preparation at this moment before 
me, taken probably at a very early period of the disease, 
shewing in the clearest manner, an alteration in the struc- 
ture of a large extent of vessel, which alteration Scarpa 
would doubtless call, a " steatomatous, earthy degenera- 
tion/' but which in my mind evinces morbid action in the 
substance of the vessel, the coats of which are not absorb- 
ed, but are morbidly changed in texture. 

Scarpa is unquestionably correct in stating the occa- 
sional ulceration of the vessel, and the removal of its 
coats by absorption, but this I maintain is a consequence 
of aneurism, and is to be considered an evidence of a 
previously morbid stale. I have now on my table a pre- 
paration in which an aneurism of the aorta has occasion- 
ed an absorption of part of the sternum, of the cartilages, 
of several ribs, and of almost every solid part in the vi- 
cinity of the vessel, and such cases are by no means 
rare. Now Scarpa's dissections* have been made at a 
point of time when this business of absorption was com- 
mencing, and very probably he is correct in observing 
that sometimes the first part absorbed, is the inner coat of 
the artery, but assuredly if this be the case, that coat was 
in a diseased state, and was removed like any other dead 
or morbid matter. 

All therefore which the learned anatomist has proved, 
is, dial the proper coats of the artery are absorbed in 
.aneurisms, but this, 1 have no doubt, is a consequence, 
and not a cause, of the disease, and I think it probable 
.hat I he removal of the inner coal by absorption, does 



200 ELEMENTS OP SURGERY. 

not take place until it has been considerably distended 
and augmented in diameter. 

Mr. Richerand in commenting upon Scarpa's doc- 
trines., pronounces them utterly unworthy of his high 
character, an opinion in which I fully concur, and am 
led to retain the usual division of aneurisms into true and 
false ; and I honestly think, that nothing can be more 
obvious than the totally distinct nature of the two cases ; 
the one consisting in disease ; the other resulting from 
accident. 

A true aneurism commences with an unusual throb- 
bing, and a small tumour at the affected part ; by pres- 
sure the swelling disappears, but returns immediately 
when the pressure is removed. If the artery be com- 
pressed between the aneurism and the heart, the tumour 
also subsides, and is reproduced by taking off the pres- 
sure. The tumour is unattended with inflammation, no 
pain or redness being visible. Gradually augmenting in 
size it attains a very great volume, and the pulsations ge- 
nerally become less evident, and in some cases they are 
quite obscured, a circumstance generally ascribed to 
the diminished action of the distended vessel, and to co- 
agulated blood, of which a considerable portion is con- 
tained in the aneurismal cavity, through which the pulsa- 
tions of the vessels are less readily felt. In a large 
aneurism it is generally impracticable entirely to remove 
the tumour by pressure, in consequence of the coagulated 
blood lining its cavity. 

The circulation of blood through the branches of the 
aneurismal vessel becomes enfeebled, and these branches 
are sometimes found of a smaller size than natural. 

In the progress of an aneurism, oedema is sometimes 
occasioned, and caries of the neighbouring bones. The 
disease, when seated in a large artery and left to itself, 
terminates in death. The substance surrounding the tu- 
mour becomes absorbed in consequence of pressure, car- 



ELEMENTS OF SURGERY. 201 

tilages, and even bones, in contact with the aneurism, are 
removed, and in many cases upon dissection the cavity of 
the aneurism appears to be formed by the surrounding 
parts, all vestige of arterial structure being lost, and a 
large portion of the neighbouring texture destroyed. 
At length the integuments become thinned, and the aneu- 
rism bursts, either from some unusual exertion, produ- 
cing a rupture of its parietes, or from the formation of a 
slough or gangrenous eschar at the external part of the 
tumour, an immense flow of blood follows, and terminates 
the existence of the patient. 

All the arteries are subject to aneurism : it is frequent- 
ly seated at the curve of the aorta, and the larger arteries 
are much oftener affected with it than the smaller, but 
not in strict proportion to their size ; next to the aorta, 
the popliteal artery is perhaps most subject to aueurism. 

The causes of aneurism are not very clearly known. 
It is not uncommon for an arterial trunk to be found af- 
fected with aneurism in several situations, and in these 
patients the vessel, when it is not yet dilated, is seen 
spotted, in various places, as if with small masses of car- 
tilage. Mr. Pelletan has counted sixty-three, of various 
sizes, in one man.* 

OP THE TREATMENT OF TRUE ANEURISM. 

Scarpa with his usual confidence states it as i( a cer- 
tain and incontrovertible fact in practical surgery that a 
complete and truly radical cure of aneurism cannot be ob- 
tained in whatever part of the body this tumour is situat- 
ed, unless the ulcerated, lacerated, or wounded artery, 
from which the aneurism is derived, is by the assistance 
of nature, or of nature combined with art, obliterated, and 

• .IVn ai compte soixante-trois sur un scul hommc depuis le volume d'une 
■ jusqu'a <<!ui de la moitie d'un ceuf de poule." Cknique Ckirur. tooi. ii. 

Vol. II. D d 



202 ELEMENTS OF SURGERY. 

converted into a perfectly solid ligamentous substances 
for a certain space above and below the ulceration, lace- 
ration, or wound." This fact asserted by Scarpa with 
respect to all aneurisms is perhaps true with respect to 
true aneurism, and it has been the custom to consider 
these cases as beyond the reach of surgery, unless in 
cases where the diseased artery can be secured and its 
cavity obliterated by the application of a ligature ; a low 
diet and occasional bloodlettings were considered as 
remedies likely only to palliate the complaint. 

Valsalva, however, appears to have entertained more 
sanguine expectations, and has accordingly carried this 
plan to a greater extent by copious and repeated blood- 
lettings and by a very abstemious diet. I have not been 
able to see his work, but in the valuable memoir of 
Mr. Pelletan upon internal aneurisms several cases are 
recorded, which the author pronounces positive cures, 
effected by the mode of treatment recommended by Val- 
salva. Some idea may be formed of the extent to which 
depletion was carried in these cases from the following 
passage. " During the first four days I prescribed eight 
bleedings of three howls* in the morning and two in the 
evening. The fifth day the pain and pulsation were 
much diminished, but the pulse preserved its fulness 
and two bowls of blood were taken at one bleeding. 
The pulse remained in a favourable state of weakness 
till the seventh day, when it became more tense, and the 
patient lost one bowl of blood in the morning and one in 
the evening."! 

During this time the patient was kept to a very ri- 
gorous diet. In twenty- eight days the patient left the 
hospital (contrary to the advice of his surgeon) but he 
never after had a symptom of aneurism. 

* The term palettes which I have tranalated bowls, generally signifies fou? 
ounces, so that three bowls or porringers, implies twelve ounces. 
fClin. Chir. torn. 1. p. 73. 



ELEMENTS OF SURGERY. 2Q3 

Although I would not he sanguine in my expecta- 
tions of curing an aneurism of the aorta, yet the testi- 
mony of Mr. Pelletan is so respectable that his treatment 
is unquestionably worthy of imitation. 

The general indication to he regarded in the treatment 
of aneurism is to effect an obliteration of the diseased 
vessel. This has been done occasionally by pressure, 
and in some instances a spontaneous cure of aneurism 
has taken place in consequence of the pressure from the 
tumour which has effectually precluded fresh blood from 
the aneurismal cavity, and has produced adhesions in the 
inner coat of the vessel which have entirely closed up 
its cavity. Such an event is however very rare, and the 
effects of pressure are by no means certain. Guattani 
unquestionably succeeded in many cases by compression, 
and Mr. Freer in his experiments on horses has proved 
that compression, may be so applied as to effect the ob- 
literation of a healthy artery. He recommends pressure 
upon a sound part of the artery above the aneurism. The 
best mode of treatment, however, is to tie up the artery 
at such a distance above the aneurism that the ligature 
may act upon a healthy portion of the vessel, and thus 
produce adhesion at that spot ; a practice introduced by 
Mr. Hunter, and founded upon the ill success attending; 
the application of ligatures upon the diseased vessel and 
the frequent and fatal hemorrhages resulting from that 
imperfect mode of treatment. He expected that if the 
artery were tied above the diseased part, the aneurismal 
tumour would cease to enlarge, and be ultimately re- 
moved by absorption. 

Mr. Hunter's first operation was performed in 1785, 
in a case of popliteal aneurism, and we shall therefore 
describe this particular aneurism first. It is the most 
frequent case demanding the surgeon's attention, and the 
principles which direct his practice in this can readily 
be applied to aueurisms in other situations, 



204 ELEMENTS OF SURGERY. 



OF POPLITEAL ANEURISM. 



In this case the tumour may be felt pulsating strongly 
in the space between the hamstrings. It occurs most 
commonly in coachmen, and the general character of 
aneurism is distinctly evident. 

When the operation is to be performed the patient is 
laid on a table, and a tourniquet placed round the upper 
part of the thigh ; an incision four inches long is then 
made on the anterior and inner part of the thigh rather 
below its middle, and this wound is continued obliquely 
across the inner edge of the sartorius muscle. The fas- 
cia covering the artery is next to be laid bare, and the 
vessel can then be very plainly felt. The fascia is now 
to be cut through along side of the artery, and the ves- 
sel is thus completely exposed. An aneurismal needle 
(a small blunt silver bodkin, curved to the shape of the 
common needle) armed with a strong double ligature of 
Avaxed thread, or strong bobbin, is to be passed round 
the artery. The ligature being cut at the eye of the 
needle, two strong ligatures are left round the artery, and 
both these are to be firmly tied the one an inch higher 
than the other, after which the artery is to be divided 
with a bistoury between the two ligatures, an improve- 
ment introduced by Mr. Abernethy, for reasons to be no- 
ticed presently. 

This operation differs in some respects from Mr. Hun- 
ter's, but I have preferred a description of what 1 con- 
sider the best method, to along detail of each successive 
improvement which the operation has undergone. 

The wound is to be dressed with adhesive plaster 
and the patient confined to bed. In general the liga- 
tures come away between the twelfth and twentieth days 
and the aneurismal tumour is gradually absorbed, or 
forms an abscess, and after a free suppuration gets well. 



ELEMENTS OF SURGERY. 205 

The operation of Mr. Hunter for popliteal aneurism, 
in some instances terminated iu fatal hemorrhage, and 
Mr. Abernethy ascribed this unfortunate event first to 
the inflammation and ulceration of the artery, and se- 
condly to the want of union between the sides of the ves- 
sel. From observing that the blood-vessels of an ampu- 
tated limb were less apt to bleed, than the femoral artery 
when tied for the cure of popliteal aneurism, Mr. Aber- 
nethy was led to place this artery in the same situation, 
by applying two ligatures and dividing the vessel be- 
tween them. In this manner the tension of the vessel is 
lessened, a retraction takes place, and the vessel con- 
tracts adhesions to the surrounding parts, and in the 
opinion of Dr. Jones founded upon very numerous expe- 
riments on brutes, the plan of Mr. Abernethy is safest 
and best. AVe should recollect in tying so important a 
vessel, the doctrines of hemorrhage developed by Dr. 
Jones, and never neglect to tie the artery as closely as 
possible to its natural connexions, and never to apply a 
ligature upon the vessel iu a situation in which it is de- 
nuded to any considerable extent. 

Mr. Astly Cooper in performing the operation in the 
manner of Mr. Abernethy, found that both the ligatures 
were forced off, and the divided artery was left which 
would have inevitably occasioned fatal hemorrhage had 
the surgeon been absent. Mr. Cline met with a similar 
case, and his son, Mr. Henry Cline, contrived a plan for 
preventing the recurrence of such an accident, which 
consists in passing each ligature, by means of a curved 
needle, through the cut extremity of the artery. 

I doubt very much the necessity of this refinement, 
and believe that wherever the ligatures are tied suffi- 
ciently tight to divide the inner coat of the artery there 
will be no reason to dread the slipping oft" of the liga- 
ture. At least I have never seen a case in which the 
ident has occurred 



206 ELEMENTS OF SURGERY. 



Or FEMORAL AND INGUINAL ANEURISMS. 

The operation last described may be performed in 
cases where the aneurism is situated near the knee, but 
the femoral artery is occasionally diseased considerably 
higher up, and in these cases it is equally necessary to 
tie the artery in a situation remote from the disease. If 
this can be done in any place below the groin the opera- 
tion differs in nothing essential from the one just de- 
scribed. It, however, in some cases happens that the 
aneurismal tumour is situated in the groin, and then it 
becomes necessary to tie up the trunk of the external 
iliac artery within the pelvis, an operation first perform- 
ed by the intrepid Abernethy, and subsequently by se- 
veral other surgeons. As I have myself met with such a 
case anil treated it successfully I shall copy the account 
of it published in the Eclectic Repertory, as the best 
method of describing the operation. 

With respect to the proper time for performing the 
operation, in this and most other instances it is safest to 
operate early, because the advantages which some sur- 
geons have expected from delaying it until the anasta- 
mosing vessels are enlarged, is more than counter- bal- 
lanced by the danger of an extension of the disease. 

CASE. 

On the 15th of August 1811, I was consulted by 
Alexander Patton, on account of a tumour in his right 
groin. The patient was a native of Aberdeenshire in 
Scotland, aged about thirty years, the last ten of which 
he had passed in America. He followed the trade of a 
cooper ; was accustomed to hard labour, and to athletic 
exercises, jumping, running and the like. He was six 
feet in height, of a robust but not corpulent habit. 



ELEMENTS OF SURGERY. 207 

Two years ago he perceived, for the first time, a small 
tumour in the right groin. Having never had the vene- 
real, nor indeed any other disease, and not having met 
with any accident, he was at a loss to account for this 
appearance. From its commencement it throbbed with 
considerable violence. For a year and four months it 
increased very slowly ; during the last eight months 
much more rapidly. In January it was no bigger than 
a walnut ; in August its shortest diameter was four in- 
ches, its longest, nearly five. It occasionally gave him 
severe pain, and at length incapacitated him from all la- 
bour. In June last (1811) he applied to Dr. Irwin of 
Easton, the place of his residence, who instantly apprized 
him of the nature and importance of the complaint, and 
advised him to come to Philadelphia. He arrived here 
the 14th of August, and was admitted next day into the 
Pennsylvania hospital. 

On examination, an aneurism was found, situated im- 
mediately below Poupart's ligament, forming a regular 
tumour in the groin, nearly hemispherical, with a kind 
of apex, where the skin appeared extremely thin, and 
discoloured as if by ecchymosis. The patient had used 
a good deal of exercise previously to his admission into 
the hospital, and had taken a drink of ram, in conse- 
quence of which his arterial system was greatly excited, 
and the tumour pulsated so violently that the bed clothes 
were bounced up with great force. He was confined to 
bed, was purged, and kept to a low diet. A consulta- 
tion was called ; and the surgeons of the house concur- 
red in recommending the operation of tying the artery as 
high as practicable above the tumour. It was determin- 
ed to perform the operation promptly ; as the disease 
was progressing, and no benefit was to be expected from 
delay. 

On Monday 19th of August, at noon, in presence of 
Or. Physick and Dr. Hartshorn, surgeons to the hospital, 



208 ELEMENTS OF SURGERY. 

and a number of medical gentlemen, I proceeded to the 
operation. The patient, having previously taken fifty 
drops of laudanum, was placed on the table. An inci- 
sion three inches and a half long, was made, beginning 
an inch and a half higher than the superior anterior spi- 
nous process of the ilium, and one inch distant from that 
process internally ; being also four inches and a half dis- 
tant from the umbilicus, extending obliquely downward 
and terminating about one inch above the basis of the tu- 
mour. This incision, which was nearly in the direction 
of the fibres of the tendon of the external oblique muscle, 
divided the skin and adipose membrane, and exposed 
that tendon, which was next cut through, the whole 
length of the external incision. The internal oblique 
muscle now protruded at the wound and was carefully 
cut through ; the inferior edge of the transversalis ab- 
dominis was next divided, but not so far upward as the 
top of the external wound. My finger was then intro- 
duced, and the cellular texture readily yielded it a pas- 
sage to the external iliac artery, the trunk of which I 
distinctly felt pulsating very strongly. With my finger 
I separated it gently from the neighbouring parts ; but 
took care to denude only a very small portion of the ves • 
sel. The peritoneum I was equally careful to detach as 
little as possible ; and not more than a square inch of it 
was disturbed. The only remaining difficulty in the 
operation was to pass the ligature round the vessel ; and 
this having been anticipated, was readily surmounted. 
Before commencing the operation, I had secured an 
aneurismal needle (a blunt bodkin of silver properly 
bent) in a pair of curved forceps, by tying the handles 
of the forceps firmly together. The needle was armed 
with strong bobbin ; and thus connected with the forceps, 
resembled a tenaculum, which could easily be managed 
outside of the wound. With one finger in the wound I 
found it very easy to direct the extremity of the needle ; 



ELEMENTS OF SURGERY. S$Q9 

and with the forceps in my other hand, to push it through 
the fascia surrounding the vessel. The string connect 
ing the handles of the forceps was now cut, and the 
needle was left under the vessel. The forceps being 
removed, the needle was drawn out, leaving the ligature 
round the artery. Convinced, by careful examination, 
that nothing but the artery was included in the ligature, 
and that it was, to the best of my judgment, natural in 
size and texture, I tied it very firmly, as high up as pos- 
sible. The pulsation of the tumour instantly ceased. 
Three knots were made, and the ends of the ligature 
were left out at the external wound. No blood-vessel of 
magnitude was divided, and not half an ounce of blood 
was lost. No stitches "were employed to close the wound ; 
a strip of adhesive plaster effectually answered this pur- 
pose. A pledget of lint was applied, and the patient was 
put to bed, his thigh being moderately flexed upon the 
pelvis. He cojnplained of extreme pain during the latter 
part of the operation, the whole of which occupied eleven 
minutes. 

The patient's pulse, for several days before the opera- 
tion, was 80 : after the operation it was 88, and rose in 
the afternoon to 100. At four o'clock he was bled ten 
ounces. At seven he complained of extreme pain in the 
back and belly, and also of some pain in the limb. He 
was not permitted to take any sustenance except toast 
and water. The superficial veins of the leg and foot 
were filled; and the whole of the limb was covered all 
the evening with perspiration. Its temperature was ex- 
amined repeatedly by a thermometer, and was five de- 
grees colder than the other. It was covered with flannel 
and carded wool. 

Tuesday 20th. Passed a restless night, in great pain. 

To use his own language, in expressing his sensations, 

-'lie felt as if his loins were tearing apart. 7 ' He was 

also troubled with pain of the bowels. Three grains of 

Vol. II, E c 



210 ELEMENTS OF SURGERY. 

calomel and ten of rhubarb were given, but without pro- 
curing a stool. In the afternoon he was bled ten ounces,, 
and a purgative injection was ordered ; after which his 
bowels were freely opened, and his pain subsided. An 
enema, consisting of a hundred drops of laudanum and 
two ounces of water, was administered, and lie soon af- 
ter fell asleep. The weather, on the day of the opera- 
tion and several days after, was very hot. The mercury 
of the thermometer in the patient's room stood at 86° 
Fahrenheit. Placed between the toes of the aneurismal 
limb, it rose to 88° ; between those of the sound limb 90° ; 
at both knees it stood at 92°. His pulse was 100 and 
tense. 

Wednesday 21st, third day after the operation. The 
sleep procured by the anodyne iujection continued all 
night. In the fore part of the day he was easy ; but in 
the evening his pain returned witli considerable fever. 
He was bled ten ounces and took ten grains of magnesia 
and as much rhubarb : this with the assistance of a clys- 
ter, brought away a large quantity of feces and flatus, 
and procured relief of all his pain. The anodyne injec- 
tion was again administered, and he soon after slept, 
His pulse 100 and somewhat tense. 

Thursday, fourth day. He slept all night, and was 
much better ; being quite free from pain and fever. His 
pulse 90. He ate some boiled rice with great relish* 
The wound was examined, and it was found that nearly 
all of it had united ; a little healthy pus surrounded the 
ligature. The limb was four degrees colder than the 
sound one. 

From this time no change of importance occurred un- 
til Sunday, 1st Sept. when the ligature came away ; viz. 
on the fourteenth day after the operation. In a few days 
more the wound cicatrized, without the occurrence of a 
single unpleasant symptom. On the twentieth day after 
the operation, his nurse being absent, he arose from bed 



ELEMENTS OF SURGERY. 211 

and walked across the mom, and has taken exercise 
every day since without inconvenience. The tumour in 
the groin diminishes slowly, and at this time is much re- 
duced in size. 

Remarks. The operation of lying up the external iliac 
artery above Poupart's ligament was tirst performed by 
Mr. Abernethy, under circumstances in which imme- 
diate death was the only alternative. He repeated it. af- 
terwards in cases of aneurism seated so high in the fe- 
moral artery as to preclude all prospect of a cure by any 
other means. He performed the operation four times. 
In the first two instances his patients died ; in the suc- 
ceeding cases they recovered.* Mr. Freer, in the Bir- 
mingham hospital, performed the operation in a case of 
inguinal aneurism with complete success ; and soon after 
another case was treated successfully by Mr. Tomlinson, 
of the same hospital. f These six cases are all that 1 
have seen related, in which the operation has been tried. 
The case I have now detailed is the seventh ; and it has 
failed in only two of these. In every instance the limb 
has been supplied with blood, which does not uniformly 
happen after the operation for popliteal aneurism. 

I wish, before closing this paper, to call the attention 
of those surgeons, who may have occasion to perform 
the operation, to the forceps, of which an engraving is 
annexed. This instrument was contrived several years 
ago by Dr. Physick for the purpose of passing a needle 
under the pudic artery, when wounded in lithotomy, and 
has since been used by him for securing bleeding arte- 
ries in deep narrow wounds. Mr. Abernethy complains 
Of " the great difficulty of turning a common needle in a 
deep narrow wound ;" and Mr. Freer was unable to pass 
his aueurismal needle round the iliac artery, until he 
punctured the fascia surrounding it with his knife, which 

•Ah 



,112' ELEMENTS OF SURGERY, 

he confesses was the most "difficult and dangerous pair? 
of the operation." These dangers and difficulties are? 
entirely obviated by means of the curved forceps ; and I< 
think the operation greatly simplified by the use of this- 
contrivance, 

Should 'this paper meet the eyes of Mr. Abernethy, I 
hope he will be gratified with the additional testimony 
of the importance of an operation for which the world is 
indebted to the intrepid efforts of true genius; and he 
will no doubt learn with pleasure, that one individual on 
this side the Atlantic owes to it, his life.* 

To this account I have only to add that the operation 
has been since performed in Dublin and in London with 
success ; it certainly affords a strong proof of the courage- 
derived from our increased knowledge of the resources 
of the animal ceconomy. The extent to which anastomo- 
sing vessels are capable of enlarging when a main ar- 
tery is obliterated, is perhaps not yet fully developed. 
Mr. Astly Cooper has made some experiments upon 
dogs, by which it appears that the aorta, both caro- 
tids, and the subclavian arteries may be tied up with- 
out destroying the life of the animal. The operation has, 
now been done in more than thirty cases, and has suc- 
ceeded in a large majority. 

OF ANEURISM OF THE CAROTID ARTERY. 

In November 1805, Mr. Astly Cooper tied up the ( a 
rotid artery in a case of aneurism, and though the pa- 
tient died on the twenty-first day, she had lived long 
enough to prove that her death did not result necessarily 
from the operation. Mr. Cooper repeated it there- 
fore on a porter aged, fifty, upon whom it succeeded 

The adjoining sketch is intended to point on' the part where the operation 
was performed, and the instrument used to convey the ligature round th< 
ry It need£ no particular explanation. 



■ar* 







■ 



m 














ELEMENT^" OF SURGERY. 2ta 

completely, and the patient was cured. Dr. Baillie and 
Mr. Hunter many years ago thought the success of this 
operation not improbable, but protested against it except 
in cases of absolute necessity. 

The following case extracted from Mr. Cooper's pub 
lication will prove sufficiently descriptive of the disease 
and operation. 

The dilatation of the carotid artery was seated just 
below the angle of the jaw, and about the acute angle 
which is made by the great division of the common caro 
tid. The tumour was about the size of a pullet's egg* 
and prominent in its middle. 

The pulsation of the aneurism on the day of the ope 
ration was remarkably strong ; when the sac was emp 
tied by pressure on the artery below, the tumour sprang 
to its original size with one contraction of the heart. 

Mr. Cooper proposed to tie the common carotid below 
the dilated part, and the operation was performed at one 
o'clock on the twenty-second of June, 1808, at Guy'- 
Hospital. 

He began his incision opposite the middle of the thy- 
roid cartilage from the base of the tumour, and extended 
it to within an inch of the clavicle, on the inner side of 
the mastoid muscle. On raising the margin of this mus- 
ele, the omo-hyoideus could be distinctly seen crossing 
the sheath of the vessels, and the nervus descend ens 
noni was also exposed. He next separated the mastoid 
from the omo-hyoideus muscle, and the jugular vein be- 
came apparent, which, being distended at .every expira- 
tion spread itself over the artery. Drawing aside the 
vein, the par vagum was evident, lying between it and 
the carotid artery, but a little to its outer side. This 
nerve was easily avoided. 

A blunt iron probe constructed for the purpose was 
then passed under the artery carrying a double ligature 
with it. Two ligaturds being thus conveyed under th^ 



214 ELEMENTS OF SURGERY. 

artery the lower was immediately tied. Mr. Cooper 
next detached the artery from the surrounding parts, to 
the extent of an inch above the lower ligature, and then 
tied the upper. Lastly a needle and thread were passed 
through the artery above one ligature and below the 
other. The division of the artery was then performed. 

Nothing now remained but to dress the patient and 
this was done by drawing the parts together by adhesive 
straps, the ligatures hanging from each end of the wound, 
and by laying on a piece of lint retained by straps of ad- 
hesive plaster. 

After the operation the patient felt relieved from a 
headache which had accompanied the formation and 
growth of the tumour, and which never afterwards re- 
turned. The pulsation of the tumour, however, did not 
entirely cease in consequence as Mr. Cooper supposed, 
of the return of blood by the internal carotid artery from 
the brain. 

This patient happily recovered ; a cough and hoarse- 
ness came on and continued a long time ; on the twenty- 
third day the upper ligature came away, aud on the 
twenty-fourth the lower, and soon after the wound heal- 
ed, the patient was discharged cured, and the tumour 
gradually disappeared. 

Mr. Cooper thinks that the aneurism in the preceding 
case was situated in the internal carotid artery, a circum- 
stance which led him t6 hope that the regurgitation of the 
blood, although at first sufficient to excite a slight pulsa- 
tion in the tumour, would not continue to support its 
growth, because as the internal carotid artery passes 
through a foramen in #w skull, a little above where the 
swelling was situated, it cOuld not dilate at that part to 
bring down any additional quantity of blood into the sac, 
so that its first effect was likely to be as great as any it 
could produce. But if the aneurism had been of the ex- 
ternal carotid artery, ovVing to the number of communi- 



ELEMENTS OF SURGERY. 215 

rating vessels, lie would not have been equally sanguine 
in his expectation that the pulsation would have ceased. 

I have great pleasure in subjoining the following very 
interesting case in which the carotid artery was tied 
up successfully by Dr. Post of New York, a gentle- 
man long distinguished as one of our ablest surgeons. 

Peter Thomas aged thirty-five, a native of the West 
Indies, was admitted into the New York Hospital Ja- 
nuary fifth 1813, with a large aneurism of the carotid 
artery, situated immediately below the angle of the jaw 
on the right side. 

The account which he gave of himself was as fol- 
lows. In March 1812, he first experienced a pulsa- 
tory sensation in the neck, hut at this time there was 
no visible tumour. A tumour was, however, soon after 
discovered on examination, which very slowly and gra- 
dually increased in size, until about two months since, 
when it began rapidly to enlarge. Previously to its last 
enlargement, he experienced no pain in it ; but now com- 
plains of an unpleasant throbbing sensation, and has 
lately had several attacks of vertigo. 

He had been bled from the arm sometime before his 
admission into the Hospital, and by some ignorant prac- 
titioner, had had several blisters applied to the tumour. 

He had never laboured under any severe indisposition, 
and bis constitution Mas robust and plethoric. For some 
considerable time before the discovery of the tumour, he 
had been occupied as a labourer to attend upon masons, 
and of course in this capacity, was frequently necessi 
tated to parry very heavy loads upon his shoulders to a 
great height. In this employ too, the frequent inclina- 
tion of the body forward would greatly favour a deter 
mination of blood to the head. 

The tumour upon being accurately measured at this 
time was found to possess the following dimensions. 



^16 ELEMENTS OF SURGERY. 









INCHES 


Length 


- 


- 


- 6* 


Breadth 


- 


. 


- 4 


Height or 


projection 


from the neck 


more 


than 


- 


. 


- 2 


Half circumference 




- 8| 



Being of a full habit of body with a strong pulse, he 
was bled from the arm to 3 xv j? took some cathartic me- 
dicine, and was ordered to live upon a light diet, to di- 
minish arterial action. 

On the seventh of the month a consultation was held, 
when it was agreed to take up the carotid artery below 
the tumour, as affording the best chance of success in the 
case. The patient, anxious to be relieved, willingly sub- 
mitted to the operation, and it was performed on the 
ninth at 12 o'clock, by Dr. Post, in the presence of a 
large number of professional gentlemen in the following 
manner : 

An incision was made from the lower part of the tu- 
mour to within a very small distance of the clavicle, of 
about three inches in length. This laid bare the inner 
edge of the sterno-mastoid muscle, and by cautiously di- 
viding the cellular substance, the sterno-hyoideus and 
the sheath containing the vessels, were exposed. The 
sheath was then divided, and the artery separated from 
the vein and par vagum. This part of the operation 
was done with great caution, sometimes using the edge 
and sometimes the handle of the scalpel, to avoid inju- 
ring either of these important vessels. An eyed probe 
properly curved and armed with a round ligature, was 
passed under the artery. The ligature was then divided; 
and the. lower one tied, and after detaching the artery 
about three-fourths of an inch from the lower ligature, 
the upper one was tied. Both ligatures being previous- 
ly armed with a small crooked needle, the lower one was 



ELEMENTS OF SURGERY. 217 

passed through the artery above the ligature, and tied a 
second time as recommended by Henry Cline jun. of 
London. The artery between the ligatures was then 
divided with a bistoury. 

It was not deemed necessary to pass the upper ligature 
through the artery, as there could be but little or no dan- 
ger of its slipping off; the force of the circulation being 
altogether resisted by the lower one ; though the arte- 
ry was at least one third larger than natural, and the 
roats uncommonly thickened. 

As soon as the first ligature was applied, the pulsa- 
tion in the tumour entirely ceased ; but in the course of 
an hour afterwards, upon being attentively examined, an 
obscure pulsatory or undulatory motion was discover- 
able. 

Afiout two minutes after the first ligature was applied, 
one of the gentlemen present having his fingers upon 
the pulse at the wrist from the commencement of the 
operation, observed a sudden diminution both of fre- 
quency and force in the stroke of the artery, so that it 
could scarcely be felt at all, and yet there was no ap- 
pearance of syncope. In about five minutes, however, 
it was restored to its former standard. The patient com- 
plained at this time, of a pressing, or sense of weight in 
the right inferior extremity, the right arm was very much 
relaxed], fell from the side of the body, and seemed de- 
prived of the power of motion. These symptoms, how- 
ever, immediately disappeared with the retain of the 
energy of the circulation! 

T*he wound was dressed by drawing the parts accu- 
rately together by straps of adhesive plaster, with the 
ligatures hanging from each angle of it ; and over these 
a piece of lint retained by adhesive plaster. No ban- 
dage was applied. The man was then carried to his 
bed, and had his head and shoulders considerably ele 
vated. 

Voi. II. Ff 



?18 ELEMENTS OF SURGERY. 

About three hours after the operation he complained 
of oppression about the upper part of the chest, and some 
pain in the right side of the head, though not of the 
throbbing kind which he felt before the operation. As 
lie complained also of chilliness and cold feet, accompa- 
nied with a small and feeble pulse, he uas ordered a 
draught of Aq. Amnion. Acetat. and Tinct. Opii — to 
drink freely of tepid drink, and have Warm applications 
to his feet. By 10 o'clock in the evening he felt very 
comfortable, except a little pain in the head — Pulse 70, 
full and soft. 

Next day, January tenth — Morning. Slept very well 
during the latter part of the night, and at present feels 
no uneasiness except a little in the head — Pulse 70 and 
full — was bled to Jxij — Four o'clock P. M. pulse 80, 
and full, in other respects much as in the morning. At 
ten in the evening his pulse being 84, strong, full and in 
some degree hard, with white tongue, and an increase of 
temperature of the skin, he was bled to %x more. 

January eleventh. Complains of stiffness and some 
uneasiness abcut the throat, but has no pain. Having 
had no alvine evacuation since the operation, was or- 
dered the Tart. Potas. and Sodse in divided doses — 
Pulse 86. 

January twelfth. The purgative operated very well. 
Early this morning after an attack of coughing, he fell 
into a state of syncope, which lasted several minutes; on 
recovering he complained of an uneasiness about the 
throat, and a difficulty In throwing up the mucus from 
the fauces — Pulse frequent and feeble, skin cold and 
covered with a copious perspiration — Ordered a more 
nourishing diet — Evening — Pulse 94 and moderately 
full — feels no pain except in the wound — Tumour does 
not appear quite so prominent as before, is harder to the 
feel — pulsation very obscure. 



ELEMENTS OF SURGERY. 219 

January thirteenth. Passed a comfortable night — Is 
troubled occasionally with fits of coughing, for which he 
was ordered Tinct. Opii. gtt. x in Jss. Sol. Glycyrrh. 
every two hours. The frequent fits of coughing have so 
deranged the dressings, (though they have been fre- 
quently re-applied) that no union by the adhesive in- 
flammation has taken place, but suppuration is coming 
on. Pulsation almost imperceptible. 

January fourteenth to twentieth. The cough was at 
times very harassing. The pain in the right side of the 
head, and on the lower part of the neck continued to be 
more or less troublesome. The bowels were kept free 
with saline cathartics, and the cough moderated by ano- 
dynes and demulcents. 

January twenty-second. The wound is granulating 
and healthy — the cough less troublesome. The dimen- 
sions of the tumour are as follows : 

1M'UK> 

Length - - H 

Breadth - 3| 

Projection - - - - 2 



I Circumference - - - 7 



January twenty-fourth. The upper ligature came away 
with the dressings. 

.1 anuary twenty-sixth. The lower ligature came away. 
The sore has very much contracted, and discharges but 
little. 

February second. The patient's general health is 
good. There is no pulsation in the tumour except at 
one part, where it is softer, and here it is very indistinct. 

February twenty-second. The wound is reduced to 
a small sinus of an inch and a half in depth — At a soft 
prominent point, near the lower part of the tumour, an 
obscure pulsation i<* still perceptible. 



220 ELEMENTS OE SURGERY. 

March twenty-third. Injections have been made of 
Sulphate of Zinc and Sulphate of Copper into the sinus, 
which is now very much contracted. The measurement 
of the tumour to day gives the following result. 

INCHES. 



Lensrth ----- 4 



*a 



Breadth ----- 2| 
Projection - - - - 1| 

. Circumference - - - - . 6§ 

May seventeenth. The sinus has been well for some 
days — Disciiaugld cured. 

J)r. Post saw the patient on the fifth of June when the 
general prominence of the tumour did not appear to have 
diminished since the last measurement ; the upper part 
was lessened, so as to leave a considerable space be- 
tween it and the angle of the jaw — the lower part had 
approached so near the clavicle as to have the cicatrix 
in part upon it. Dr. Post was of opinion that had the 
tumour been situated as close to the clavicle before the 
operation, there would not have been room enough to 
have taken up the artery. 

Dr. Post has since operated ou another case of carotid 
aneurism, and the tumour having been reproduced by 
anastomising vessels, he intends to tic up the other 
carotid of the same patient. I feel no small share of 
interest in the result, and am truly solicitous that suc- 
cess may crown so eutcrprizing an effort. 

Mr. Charles Collier took up the carotid artery, to pre 
vent a fatal hemorrhagy from a wound in the mouth ; and 
Mr. Goodladtied it up previously to removing a tumour 
from the face and neck, in neither case did any serious 
consequences result. 

aneurism of the axillary artery. 

Another situation in which aneurism sometimes occurs 



ELEMENTS OF SURGERY. 221 

is in the axillary, or high in the brachial artery. The 
usual symptoms of aneurism generally attend this case. 
•Jut Mr. Pelletan relates an instance in which no arterial 
pulsation could he discovered, and the tumour was mis- 
taken for an abscess ; a puncture being made a gush of 
arterial blood announced the nature of the disease, and 
though the puncture was healed yet the mistake had 
nearly proved fatal. Of late years the success of those 
daring operations already described has encouraged sur 
geons to tic up the subclavian artery in cases of axillary 
aneurism. 

In the year 1786, before the successful performance 
of any of these operations, however, a case of axillary 
aneurism occurred in the practice of Mr. Pelletan, who 
received the patient " more with a view to study his dis- 
ease than with a hope of curing it." He found after 
many examinations of this patient, that upon raising the 
arm and clavicle he could distinctly feel the subclavian 
artery, in a manner insulated, and by compressing it 
with the finger the pulsations of the tumour were imme- 
diately stopped, lie accordingly determined to tie up 
the artery in this situation. 

It appears from Mr. Pelletan's candid and very inte- 
resting account of his operation that he was prevented 
from carrying his own plan into effect, and therefore he 
made an unsuccessful attempt to take up the vessel, and 
the patient soon after expiring, gave him an opportunity 
to prove, by dissection the practicability of tying up the 
subclavian artery in such a situation as to have cut off 
all access of blood to the tumour. Mr. Pelletan suggests 
the propriety, in cases where this is totally impracticable, 
of tying the artery below the tumour, under an expecta- 
tion that the course of the blood being interrupted through 
the main channel, another route would be established 
and the progress of the disease arrested — an idea total- 
ly improbable, and an operation by no means likely to 



222 ELEMENTS OF SURGERY. 

succeed. Desault also tied the axillary artery without 
success. 

That the mere obstruction of the subclavian artery 
will not necessarily occasion gangrene of the arm is de- 
monstrated by a case recorded by Mr. Hall, in which 
this artery was divided by a sithe and being taken up 
the patient recovered, and regained the use of his arm. 

Mr. Keate has detailed so far as I know the first case 
in which an axillary aneurism has been successfully 
treated by a ligature on the subclavian artery. This pa- 
tient was a soldier twenty-five years of age. In Octo- 
ber 1799 he was wounded in the hand, and three fingers 
were amputated. The stumps did not soon heal and 
collections of matter formed near his wrist — an aneuris- 
mal tumour was soon after found in the axilla which be- 
came very prominent and was attended with a strong 
pulsation. The parietes of this aneurism became ex- 
tremely thin, and at length were ruptured, and the he- 
morrhage for a time was commanded by pressure. In 
this situation Mr. Keate determined to take up the ar- 
tery in its passage over the first rib. Accordingly he 
made an incision obliquely downwards, divided the 
fibres of the pectoral muscle that lay in his way, and 
when he came to the artery he passed a curved blunt 
pointed silver needle armed double, as he conceived 
under the artery, and tied two of the ends ; after a c?a-e- 
ful examination he found that the artery pulsated below 
the ligature, and he deternihmed to pass another ligature 
higher up and nearer to the clavicle. He accordingly 
passed the needle deeper evidently including the artery. 
This operation proved completely successM, no gan- 
grene resulted, and the patient gradually acquired the 
use of his arm as well as before the accident. 

Mr. Ramsden of London has published a case in 
which the subclavian artery was tied up, and although 
the event was fatal yet the mode of operating is des- 



ELEMENTS OF SURGERY. 223 

cribed so clearly that I shall relate the principal circum- 
stances of the case. 

The patient was twenty-two years of age — a perfect 
sot. The tumour was as large as half of an orange. 
Pulse and temperature in both arms similar. He had 
not remained long in St. Bartholomew's Hospital before 
a dark spot appeared on the centre of the tumour in- 
dicative of gangrene, and the operation was accordingly 
performed in the following manner. 

The patient being placed upon an operating table 
with his head obliquely towards the light and the af- 
fected arm supported by an assistant at an easy distance 
from the side; J made" says Mr. Kamsdcn "a trans- 
verse incision through the skin and platysma myoides 
along and upon the upper edge of the clavicle of about 
two inches and a half in length, beginning it nearest to 
the shoulder, and terminating its inner extremity at about 
half an inch within the outward edge of the sleino-cleido- 
hiastoidcus muscle. This incision divided a small su 
perficial artery, which was directly secured. The skin 
above the clavicle being then pinched up between mv 
thumb and linger and those of an assistant, I divided 
it from within outwards and upwards in the line of the 
outward edge of the stcrno-cleido-mastoideus muscle to 
the extent of two inches. 

" My object in pinching up the skin for the second in- 
cision was to expose at once the superficial veins, and 
by dissecting them carefully from the cellular membrane 
to place them out of my way without wounding them. 
This provision proved to be very useful, for it rendered 
the How of blood during the operation very trifling com- 
paratively with what might otherwise have been ex 
pected ; and thereby enabled me with the greatest faci 
lity to bring into view those parts which were to direct 
rue to the artery 



224 ELEMENTS OF SURGERY. 

« My assistant having now lowered the shoulder* for 
the purpose of placing the first incision above the clavi- 
cle (which I had designedly made along and upon that 
bone), I continued the dissection with my scalpel until I 
had distinctly brought into sight the edge of the anterior 
scalenus muscle, immediately below the angle, which is 
formed by the traversing-bellies of the omohyoideus and 
the edge of the sterno-cleido-mastoideus, and having 
placed my finger on the artery at the point where it pre- 
sents itself between the scaleni, I found no difficulty in 
tracing it, without touching any of the nerves, to the 
lower edge of the upper rib, at which part I detached it 
with my finger nail, for the purpose of applying the liga- 
ture. 

" Here however arose an embarrassment which (al- 
though I was not unprepared for it) greatly exceeded my 
expectation. I had learned from repeatedly performing 
this operation many years since on the dead subject, that 
to pass the ligature under the subclavian artery, with the 
needle commonly used in aneurisms would be impracti- 
cable; I had therefore provided myself with instruments 
of various forms and curvatures to meet the difficulty, 
each of which conveyed most readily the ligature un- 
derneath the artery but would serve me no farther ; for, 
being made of solid materials, and fixed into handles, 
they would not allow of their points being brought up 
again at the very short curvature which the narrowness 
of the space between the rib and the clavicle afforded, 
and which in this particular case was rendered of un- 
usual depth by the previous elevation of the shoulder, 
by the tumour. 

« After trying various means to overcome this difficul- 

* " In my first incision I intentionally cut down along and upon the clavicle, as 
a security against wounding any superficial vessels, a very little lowering of the 
shoulder therefore placed the incision in the situation I wished to have it for 
the purpose of proceeding with the operation." 



ELEMENTS OF SURGERY. 225 

ty, a probe of ductile metal was at length handed me, 
which I passed under the artery, and bringing up its 
point with a pair of forceps, I succeeded in passing on 
the ligature, and then tied the subclavian artery at the 
part, where I had previously detached it for that pur- 
pose. The drawing of the knot was unattended with pain, 
the wound was closed by the dry suture, and the patient 
was then returned to his bed." 

Mr. Ramsden's patient died on the fifth day after the 
operation, but the practicability of the operation is demon- 
strated by the case, and there occurred nothing in the 
subsequent symptoms to forbid a similar attempt in a 
similar instance. 

With respect to the best situation in which to apply 
the ligature in the present instance, that must be de- 
rided by the nature of the case, and the size and situation 
of the tumour — the most accessible part of the sound 
artery is to be preferred. To find this spot there are no 
directions necessary ; an accurate knowledge of the ana- 
tomy of the parts is indispensable, but the surgeon will 
always recollect one material difference between the 
living and dead body, too much overlooked, the pul- 
sation of the artery, which in operations for aneurism 
is a most important guide. 

Having never performed the operation upon the living 
subject ] speak diffidently as to the best method, but I 
have no doubt that the needle in curved forceps such as 
I have recommended in tying the pudic and iliac ar- 
teries, would greatly facilitate the passing of a ligature 
round the subclavian. 

OF TYING THE ARTERIA 1NN0MINATA. 

A case has recently occurred in which Dr. Mott, pro 
lessor of surgery, in the university of New York, se- 
cured the arteria iunominatn. A p account of this opera- 
Vol. II. Ci a: 



226 ELEMENTS OF SURGERY. 

tron will speedily be published, and the medical world 
will then be enabled to estimate their obligations to this 
intrepid surgeon, who has certainly demonstrated that 
the circulation in the arm will not be necessarily de- 
stroyed by securing this vessel ; his patient having sur- 
vived the operation nearly four weeks. 

I heartily regret the fatal result of this operation, 
which promised to throw additional lustre on American 
surgery, and on the distinguished name of the gentleman 
who performed it. Until I have an opportunity how- 
ever of examining the details of the case, I can offer no 
opinion of the proper method of performing such an 
operation, nor of the cases demanding it. 

OF TYING THE AORTA. 

To complete my account of aneurism, it is necessary 
to insert Mr. Cooper's case, which I regard as the most 
daring deed recorded in the annals of chirurgical history, 
but I must add, perfectly justifiable and highly honour- 
able to a name already celebrated in all quarters of the 
globe. 

"I fear that the title of this paper may impress the 
reader with an idea that nothing could justify me in per- 
forming the operation which 1 am about to describe ; for 
that a ligature made upon the aorta must necessarily 
prove fatal. But I trust, that it will be seen in the se- 
quel, that the operation was not attended with the im- 
mediate danger which might have been apprehended ; 
that the patient complained of but little pain during its 
performance, that it afforded the only hope of safety^ 
and that we had to lament, not that the operation was 
performed, but that it had not been sooner done. 

" Sorry indeed should I be, to sport with the life of a 
fellow- creature who might repose a confidence either in 
my surgical knowledge or in my humanity ; and I should 



ELEMENTS OF 9URGERY. 227 

be equally disposed to consider myself culpable, if I did 
Hot make every possible effort to save a person, whose 
death was rendered inevitable, if a disease were suffer- 
ed to continue which it was possible for surgery to re- 
lieve, as in the case which forms the subject of this 
essay. In the performance of our duty one feeling 
should direct us ; the case we should consider as our 
own, and we should ask ourselves, whether, placed 
under similar circumstances, we should choose to submit 
to the pain and danger we are about to inflict Guided 
by this principle, and having collected all the evidence 
which applies to the case, we perform our duty without 
the reproaches of conscience which must await those 
who unnecessarily subject their patients to pain and 
danger. 

" Those who feel disposed to condemn the attempt 
which I have here described, will have the kindness to 
recollect, that although my first operation for carotid 
aneurism proved equally unfortunate with this, yet in 
the second operation, I was gratified by the successful 
issue of the case. 

"In collecting evidence upon any medical subject, there 
are but three sources from which we can hope to obtain 
it ; viz. from observation on the living subject ; from 
examination of the dead ; and from experiments upon 
living animals. By the first, we learn the history of 
disease ; by the second, its real nature, so far as it can 
be certainly known ; and by experiments upon living 
animals, we ascertain the processes resorted to by nature 
for restoring parts which have sustained injuries, and 
then apply that knowledge to accidents in man. 

"In applying ligatures upon the arteries generally, the 
only circumstance to be considered is, the probability of 
the blood being conveyed by means of anastomosis to 
the parts beyond ; but in operations upon those arteries, 
v/hirh are seated in the larger cavities of the body, it 



228 ELEMENTS OF SURGERY. 

becomes a subject of consideration, by what mode the 
ligature shall be prevented from occasioning destruction, 
In common parts, it produces suppuration and ulceration, 
which end in the separation of the ligature ; but amidst 
the vital organs, a suppurative process may endanger 
life. 

" The Aorta is so rarely obstructed, that the opportu- 
nity of ascertaining the power of anastomosing vessels 
in propelling the blood is extremely unfrequent. The 
first impression arising on examination of the structure 
of the aorta at its curvature would be, that an anastomo- 
sis would not be sufficiently free to permit the blood to 
find its course by circuitous channels ; and the only op- 
portunity that I have had of seeing a contracted aorta 
in the human subject would serve to confirm that opin- 
ion : but Mr. Graham has met with a case (which will 
hereafter be detailed) which shews that even in that part 
of the aorta, the communication may be sufficient to allow 
a passage to the blood. 

" With respect to the case of contracted aorta, which 
1 had the opportunity of seeing, the following are the par- 
ticulars, as given to me by Mr. Winstone, Surgeon, of 
Charter- house Square, who solicited me to inspect the 
dead body : — 

" < The gentleman, who formed the subject of it, was 
57 years of age, of a full habit, accustomed to free living; 
had been in good health for years, excepting in the win- 
ter, when he was always troubled with a violent cough ; 
more violent than I ever witnessed in any other person. 
In the night of April the 7 th, 1809, he was affected 
wiili cough and difficulty of breathing to a greater de- 
gree than usual : and at five in the morning I saw him. 
He complained of pain under the sternum, the extremi- 
ties were cold, the countenance exhibited marks of inex- 
pressible anxiety : the pulse was rather weak, but regular, 
and much altered in frequency. These symptoms con- 



ELEMENTS OF SUItUEIU. 229 

tinued with but little alteration, notwithstanding cupping 
on the sternum, blistering and volatile medicines, until 
about eleven o'clock, when he was prevailed upon to go 
to bed. He walked up stairs, and fell on the bed life- 
less.' " 

" Upon our opening the body, the pericardium imme- 
diately presented itself, exceedingly distended ; and on 
making an incision into it, a large quantity of blood was 
discharged ; upon examination of the heart, one of the 
coronary veins was found ruptured on the anterior sur- 
face of the right ventricle. At first I supposed this was 
the source of the blood found in the pericardium : but 
upon more minute examination of the heart, when I had 
brought it to my house, I found an opening leading into 
the right ventricle, and that the rupture had begun in 
this part of the heart and extended through its substance, 
bursting the vein in its progress. I opened the pulmo- 
nary artery, but found it free from disease ; the left side 
of the heart was also healthy, but the lungs adhered in 
some degree to the inner side of the chest, and a small 
quantity of fluid was found in each remaining portion of 
the cavity of the thorax. The finger being thrust into 
the aorta, opposite to that part at which the canalis 
arteriosus terminates, a stricture was discovered in it, 
which with difficulty admitted the little finger, and which, 
on more particular examination, was found to be a thick- 
ening of the circular fibrous structure of the vessel, ac- 
companied with some ossification of its coats. This 
state of contraction in the aorta impeded the passage of 
the blood through the heart and lungs, and under the 
extreme degree of distention thus produced, the right 
ventricle, from its less power of resistance, gave way, 
and occasioned the sudden termination of the patient's 
existence. 

u The following case has been published in the Medi- 
co- Chirurgical Transactions, by Mr. Graham. Physician 



230 ELEMENTS OF SURGERY. 

to the Infirmary, Glasgow. — (Vide Medico- Chirurgical 
Transactions, Vol. V.) 

« < The case which I take the liberty of transmitting 
to the Medical and Chirnrgical Society, has, as far as I 
know, but one parallel on record ; and in it the appear- 
ances on dissection only are mentioned ; no history is 
given of the case. I believe, I have extracted from the 
books of the infirmary, such parts of the reports taken 
at the patient's bed-side as are of any importance, and 
have noted some anomalous symptoms which may now 
appear trifling ; because it may perhaps be found that 
an improved state of knowledge may give importance to 
what at present seems adventitious, and without value. 
I am sorry to say, that as I can see no diagnostic symp- 
tom, the occurrence of this derangement adds but another 
chance to our guessing wrong during life, at the diseases 
of the heart. 

" Henry Frere, 14 years of age, a weaver, admitted 
into the infirmary the 3d of August, 1813, where the 
following history of his symptoms was entered on the 
journal of the house : — 

" i Two weeks ago, after exposure to cold, was affect- 
ed with dry cough, which, for the last eight days has 
been attended with tolerably copious expectoration and 
pain, impeding respiration, and excited by the cough, 
in the left side of the chest ; pulse 100, somewhat firm ; 
little appetite ; much thirst ; tougue rather white ; bowels 
regular ; sleeps ill ; sweats considerably ; has used no 
medicines.' n 

" The disease was regarded as a case of pneumonia, 
but of such standing, that suppuration seemed to have 
taken place, and in which, therefore, no material benefit 
was likely to result from any treatment. However, under 
the ordinary means, bleeding, blistering, expectorants, 
and the free use of cathartics, I had the satisfaction of 



ELEMENTS OF SURGERY. 231 

seeing the symptoms decline. The blood from the first 
bleeding presented somewhat of the buff coat. The 
pulse, however, generally ranged from 92 to 104, and 
is variously marked in the reports ; full, strong, sharp : 
it was always regular. The sputum became more copi- 
ous, gross, and tinged with blood. He perspired chiefly 
from the upper parts of the body, moaned in his sleep, 
and took little food. On the 8th he was affected with 
nausea and vomiting. On the 19th he had a febrile at- 
tack, which lasted a few days. Ou the 20th there was 
much pain in the left eye-ball. On the 27th he com- 
plained only of palpitation — the first time that symptom 
is noticed in the journal, though I rather think this was 
an oversight. No report was taken from this date till 
the 6th of October, when he was dismissed from the 
hospital <•' cured." 

"The palpitation had subsided as the strength increa- 
sed ; which encouraged a hope I was willing to entertain, 
that this symptom proceeded from weakness, though I 
could not but express fears that the inflammation had 
extended to the pericardium or the heart. The uncer- 
tainty of the diagnosis in cases of this kind, is but too 
well known to every practitioner. I was inclined to 
suspect the effusion of serum within the pericardium, or 
perhaps adhesion of the heart to its capsule, though I 
had seen at least two cases about that time of the most 
intimate and general adhesion, without the circulation 
having been in any degree affected. 

" These fears were much strengthened by the boy's 
appearance on returning to the hospital on the 13th of 
November, when the throbbing of the carotid and sub- 
clavian arteries was very remarkable. On his re-ad- 
mission, the following report appears on the journal : — 

" <■ 13th JV*0i>e?ra&er.-Dyspncea, palpitation at the heart, 
and pain in the left side of the thorax returned soon after 
he left the house, and have been gradually increasing ; 



232 ELEMENTS OF SURGERY. 

pulse 88, regular, bowels kept open by physic ; received 
temporary relief from the application of a blister.' 9i 

" Blisters and cathartics were again employed, and 
the symptoms for a time declined. The pain, which had 
been removed, returned to the left side of the chest on 
the evening of the 29th. A blister was repeated next 
day, which gave much pain, till he was suddenly seized 
with a febrile attack on the 2d of December, when the 
part became quite easy. There was no strangury. The 
fever was gone next day. A similar attack, accompani- 
ed with nausea and vomiting, was experienced on the 
12th, and immediately removed by the operation of an 
emetic. He had acidity at the stomach, and cardialgia 
after meals. On the 23d, he is reported as having been 
affected for ten days with pain in the right side of the 
chest, increased by motion, and by full inspiration, ac- 
companied by frequent cough, most troublesome in the 
night. The pulse had again risen ; he was blistered, 
used cathartics, and was twice bled ; the blood, espe- 
cially after the first operation, being very buffy. The 
pulse subsided, and the pain was removed, but the cough 
and palpitation continued. The circulation was again 
quickened on the 27th, and remained hurried till his 
death ; he sunk at length ; was drenched in perspiration : 
took no food ; was attacked with frequent vomiting : the 
urine became sandy ; his sleep was disturbed ; the 
dyspnoea and palpitations increased, and he expired 
about noon on the 2d of January. The pulse, while he 
was last in the hospital, fluctuated from 90 to 116, and 
was of various degrees of strength and firmness : latter- 
ly only, weak : it was always regular. 

DISSECTION. 

" There was nearly a pound of serum in the cavity of 
the abdomen, and the bowels were distended with flatus, 



ELEMENTS OF SURGERY. 233 

but the viscera seemed natural. Immediately on turning 
up the sternum, the pericardium presented itself very 
much enlarged, obscuring the left lung, and adhering to 
the pleura costalis. This capsule, which was thin and 
beautifully transparent, contained about an ounce of 
fluid, and a heart nearly twice its natural size for a boy 
of this age. The arteries and trachea were distended 
above the arch of the aorta ; the contents of the thorax 
were turned downwards ; and the aorta, being divided 
below the whole, was removed from the body. The 
walls of the left ventricle were about an inch in thick- 
ness, but no other derangement in the structure of the 
heart or its valves, was observed. The capacity of the 
cavities seemed natural. The aorta expanded unusually 
near its origin, so as to form a kind of pouch, but after 
. having given off the branches to the head and superior 
extremities, its diameter was pretcrnatu rally contracted. 
It was continued of this diminished size till after its 
union with the canalis arteriosus, where it was com- 
pletely impervious. The coats were not thickened, or 
in any way diseased, except that about half an inch 
below the stricture, there was a smooth elevation on the 
inner surface, less raised, but having nearly the diame- 
ter of a split pea; otherwise the appearance was exactly 
such as if a ligature had been tied tightly round the 
artery. The obstruction was about a line in breadth. 
The artery then received three trunks about the size of 
crow quills, and near them three smaller ones, after- 
wards resuming its natural size along the vertebrae. 
These three trunks are evidently the uppermost of the 
inferior intercostal* ; their coats were remarkably thin, 
like those of veins. A probe passed from the pulmonary 
artery along the canalis arteriosus to the obstructed por- 
tion of the aorta ; but from its thickened appearance, it 
did not seem probable much communication by means 
of it could have been allowed, and the florid countenance 
Vol. II. H U 



234 ELEMENTS OF SURGERY. 

of the boy during life establishes the same conclusion. 
There having been no suspicion of this singular devia- 
tion from the natural structure till after the contents of 
the thorax were removed from the body, it was impossi- 
ble to trace, with the accuracy that could be wished, the 
anastomosing branches by which the circulation had been 
carried on in the inferior parts of the body ; but I think 
enough has been observed to lead us very near the truth. 
The arteria innominata, the left subclavian, the superior 
intercostals, and the mammary arteries, were much en- 
larged. The epigastric was reported to be of its natural 
size. These facts, and the aorta acquiring at least very 
nearly its natural size immediately below the stricture, 
shew that the blood did not pass to the inferior extremi- 
ties, in any material quantity, as might perhaps have 
been expected, by the inosculations of the mammary 
and epigastric arteries, but chiefly by the communications 
of the superior intercostals and the mammary arteries 
with the three large branches entering the aorta below 
the stricture : also from the mammaries and thoracics 
through others of the intercostal and diaphragmatic ar- 
teries. 

" The lungs were very light coloured ; the left lobe 
much collapsed. In each side of the thorax there was 
a small quantity of bloody serum." 

" After the aorta has formed its curvature, it gives off 
numerous intercostal arteries within the cavity of the 
chest ; and though these vessels are small, they com- 
municate so freely with each other, that under a gradual 
obliteration of the aorta, the blood would be still readily 
transmitted to the inferior parts of the body. An ex- 
ample of this kind is related by Mr. Paris, and is 
quoted by Mr. John Bell, in his Surgical Observations. 

" Mr. Paris, Dissector for the Amphitheatre of the 
Hotel-Dieu, in the year 1789, injected the body of a 



ELEMENTS OF SURGERY. 235 

^ery lean old woman, about 50 years of age, whose ar- 
terial system was found to be singularly deranged, and 
the circle of the blood changed altogether by a complete 
contraction of the aorta a little beyond the arch. Mr. 
Paris had his attention particularly excited to the con- 
dition of this subject by the unaccountable enlargement 
of the small arteries upon the fore part of the chest. He 
had filled the arteries with an injection composed of 
equal parts of suet and resin, coloured with lampblack; 
and this injection, thrown in from the mouth of the aorta, 
passed along so easily, that far from suspecting an obli- 
teration, he felt that he could have thrown in more in- 
jection than is usually required for filling an adult body. 

" The subject was so meagre, that, without dissecting, 
Mr. Paris felt the thoracic arteries running down the 
sides of the chest tortuous and remarkably enlarged. It 
was natural for him to be very careful in the dissection 
of this subject. He found the aorta immediately beyond 
its arch contracted to the size of a writing quill ; the 
coats of the artery were of their usual thickness, and its 
cavity of course extremely small ; the arch of the aorta, 
above this contraction was but very slightly dilated ; the. 
part below had lost nothing of its natural size. Nothing 
could be found either in its own structure, or in the con- 
dition of the neighbouring parts, to account for this con- 
traction of the artery. 

u The carotids were in the natural state ; the arteria 
innominata, and the left subclavian were enlarged to 
twice their natural diameter ; all their smaller branches 
were increased in the same proportion, and had assumed 
a curled and zigzag course : the internal mammary and 
phrenic arteries were greatly enlarged and very tortu- 
ous. The transverse arteries of the neck were of twice 
their natural size ; their posterior branches were tortu- 
ous, extending to a great distance over the back, with 
long inosculations which were met from below by the 



236 ELEMENTS OF SURGERY. 

branches of the upper intercostal arteries, and they were 
also remarkably enlarged : the thoracic and scapular 
arteries which run along the side of the chest, were 
twice their natural size. 

" Below the constricted part of the aorta, the lower in- 
tercostals were remarkably enlarged, even to three or 
four times their natural size; each of them was dilated, 
but those were most affected which were given off near- 
est the contracted part ; and the posterior branch of each, 
which penetrates to the muscles of the back, was more, 
dilated than that which runs between the ribs : indeed, 
those posterior branches were so remarkably dilated 
witli contortions so closely succeeding each other, that 
they resembled a necklace of beads ; and their inoscu- 
lations with the branches of the transversalis cervicls 
were very remarkable. The lower phrenic artery was 
enlarged, forming considerable inosculations with the 
superior phrenic ; the epigastric artery was dilated to 
the size of the enlarged mammary, and was joined with 
it by very numerous and conspicuous inosculations !" 
This case clearly demonstrates, that the greater part of 
the blood, usually conveyed by means of the aorta 
through the thorax, is capable of finding a circuitous 
course by the branches of the subclavian and intercostal 
arteries. 

itf "With respect to the aorta in the abdomen, I have met 
with no instance in the human subject of its obliteration 
or contraction : but if such an event were to occur, little 
difficulty could arise iu the transmission of blood by 
collateral channels : the mammary and epigastric, the 
superior and inferior mesenteries, and the lumbar arte- 
ries would furnish abundant opportunity for a collateral 
course of the blood. 

" Although in the human subject we arc thus deficient 
in evidence concerning a circuitous circulation in the 



ELEMENTS OF SURGERY. 237 

cavity of the abdomen, yet with respect to other animals, 
it is probably generally known, that I have several 
times made ligatures upon the aorta of the dog, and 
found that the blood was readily carried by anastomo- 
sing vessels to the posterior extremities of the animal. 
Of which experiments an account has been published in 
the Medico- Chirurgical Transactions. 

" The incision was, in each experiment, made on the 
left side of the spine, the aorta was drawn to the surface 
of the skin by an aneurismal needle, and all the sur- 
rounding parts being separated from the vessel, so as 
to perfectly bare its coats, a ligature was applied around 
it. An animal under these circumstances was kept for 
a few weeks, and then killed : being injected and dis- 
sected, the lumbar arteries, which were considerably 
enlarged, were found to be the chief agents of the new 
circulation. We have a beautiful preparation in the 
collection at St. Thomas's Hospital, shewing the obli- 
terated aorta, and the numerous and enlarged anasto- 
mosing vessels which carried on the circulation ; thus 
establishing, as far as analogy could go, the possibility 
of the blood being transmitted in a similar manner in the 
human subject. 

i i I shall now r proceed to detail the circumstances of the 
case, which forms the principal object of this Paper, 
leaving the remarks upon the kind of ligature to be em- 
ployed till a description of the operatiou has been given. 

CASE. 

" Charles Hutson, a porter, aged 38 years, was ad- 
mitted into Guy's Hospital April 9. 1817, for a swelling 
in the left groin, situated partly above, and partly below 
Poupart's ligament. An obscure pulsation could beper- 
ceived in it, and it was concluded to be an aneurism. 
The history which he gave of himself was, that thirteen 



238 ELEMENTS OF SURGERY. 

months previous to his admission, he had fallen against 
the corner of a chest, by which accident he received a 
violent blow upon the left groin, and was so much hurt 
as to be unable to walk to his home. On the following 
day, his thigh became so much discoloured and swollen, 
that he could not rise from his bed. 

i( After a confinement of three weeks, he began to re- 
cover, and the limb soon returning to its natural size, he 
resumed his employment, but was never able to exert 
that limb with the same freedom as the other : however, 
he continued to work, though with the greatest difficulty, 
till within a fortnight of his admission into the hospital : 
for some time previous to which, he had been occasion- 
ally troubled with a pricking sensation in the limb, but 
it was only transient, and seemed to arise from the 
pressure of the swelling upon the anterior crural nerve. 
Some degree of swelling had remained in the groin from 
the time of the accident ; and for some weeks previous 
to his admission, he had been obliged to loosen his 
clothes on the left side. 

" At this period the swelling was considerably diffu- 
sed, several large veins crossed its surface, and pressure 
upon it gave considerable pain. On the third day after 
he had been in the hospital, the swelling increased to 
double its former size, and the pulsation became less 
distinct, excepting in the course of the iliac and femoral 
arteries. The swelling extended from three to four 
inches above Poupart's ligament, to an equal distance 
below it, and was of great magnitude. Just below the 
anterior and superior spinous process of the ilium, a dis- 
tinct fluctuation could be perceived in the aneurismal 
sac above Poupart's ligament, so that the blood had evi- 
dently not yet coagulated ; and the peritoneum was car- 
ried far from the lower part of the abdomen, in such a 
manner as to reach the common iliac artery, and to ren- 
der an operation impracticable without opening the ca- 



ELEMENTS OF SURGERY. 239 

vity of the peritoneum. I therefore determined to avail 
myself of other means, or to wait the efforts of nature 
towards a spontaneous cure, before I performed any 
operation ; a circumstance which it is well known every 
now and then occurs. 

"May 16. — The swelling had suddenly increased ; 
and the pulsation becoming more distinct, twelve ounces 
of blood were ordered to be taken from the arm. 

"21. — Pressure was applied upon the fore part of the 
swelling, by means of a cushion bound down upon it by 
a broad roller; twelve ounces of blood being drawn 
from his arm, the patient declared himself to be more at 
ease. 

"27. — The pressure upon the tumour being removed, 
the skin was found abraded and discoloured, with the 
loss of its sensibility. 

" 30. — In the morning he reported, that he had passed 
a restless night, and appeared to labour under consider- 
able constitutional irritation. The swelling had very 
much increased ; a tourniquet was ordered to be applied 
upon it, with directions to adjust it in such a manner as 
to press upon the aneurism, but upon the surrounding 
parts as little as possible. 

"Jane 1. — He had borne the pressure of the tourni- 
quet tolerably well, but it made no difference in the size 
of the tumour. 

"4. — When the tourniquet was loosened, a slight 
ulceration of the skin over the sac was observed, and it 
was therefore ordered not te be re-applied. 

"5. — He complained of the limb feeling so excessively 
heavy, that he had difficulty in raising it. The skin 
over the aneurism is shewing a disposition to slough. 

" 19. — A slough was observed on the exterior part of 
the swelling below Poupart's ligament, which had nearly 
separated with a deep ulceration around it. 

" 20. — At ten in the morning he had a bleeding from 



240 ELEMENTS OF SURGERY. 

the external part of the sac, but the loss of blood was 
not considerable. A compress of lint was applied, and 
confined by adhesive plaster. He had no return of 
bleeding on the following day. 

" 22. — At 7 o'clock in the morning, after some slight 
exertion, he bled again ; but still the bleeding was not 
profuse. 

"24. — The bleeding again recurred, but stopped 
spontaneously. 

" 25. — About half-past two o'clock in the afternoon, 
in consequence of a sudden mental agitation, he bled 
profusely. My apprentice, Mr. Key, fortunately suc- 
ceeded in preventing his immediate dissolution by pres- 
sure, but the man was so much exhausted, that the faeces 
were passed involuntarily. 

" At 9 o'clock the same evening I saw him, and found 
him in so reduced a state, that he could not survive 
another haemorrhage, with which he was every moment 
threatened. Yet, still anxious to avoid opening the ab- 
domen, to secure the aorta near to its bifurcation, I de- 
termined to ascertain whether it were practicable to pass 
a ligature around the artery from within the aneurismal 
sac ; for I was of opinion, that if the artery had given 
way near the centre of the sac, as it usually does in 
aneurism, I might compress it with my finger, and pass 
a thread around it. With this view, I made a small 
incision upon the aneurism, about two inches above Pou- 
part's ligament : and having made a very small opening 
into the sac, I passed my finger easily into it, and felt 
for the artery upon which it was formed ; in doing which, 
my finger so completely filled the opening, that it pre- 
vented the escape of any blood by its side. I moved 
the finger to feel for the artery, but found only a chaos 
of broken coagula, and that the artery entered the sac 
above and quitted it below, without there being any in- 
tervening portion of vessel ; and therefore, was con 



ELEMENTS OF SURGERY. 241 

strained to abandon that mode of operation. When I 
was about to withdraw my finger, I directed two of the 
students to compress with their hands the aorta upon 
the spine, and they succeeded in stoppiug the pulsation 
in the artery of the right groin. As I withdrew my 
finger, I put a dossil of lint by its side, and closed the 
opening which I had made into the sac. 

"It is proper here to observe, that the aperture made 
into the aneurism by the sloughing process, was situa- 
ted too far from the natural seat of the artery, to allow 
a hope of my finger reaching it from thence. As I was 
quitting the patient's bed side, I felt a great regret, in 
which all the students by whom I was surrounded joined 
me, that the patient should be left to perish, without 
giving him the only chance which remained of prevent- 
ing his immediate dissolution from haemorrhage, by tying 
the aorta; and I therefore said, "Gentlemen, this only 
hope of safety I am determined to give him." 

u The operation was performed as follows : The pa- 
tient's shoulders were slightly elevated by pillows, in 
order to relax, as much as possible, the abdominal mus- 
cles ; for T expected that a protrusion of the intestines 
would produce embarrassment in the operation, and was 
greatly gratified to find that this was prevented by their 
empty state, in consequence of the involuntary evacua- 
tion of the faeces ; and here let me remark that I should, 
in a similar operation, consider it absolutely necessary, 
previously to empty the bowels by active aperient medi- 
rioes. 

" I then made an incision three inches long into the 
linea alba, giving it a slight curve to avoid the umbili- 
cus : one inch and a half was above, and the remainder 
below the navel, and the inclination of the incision was 
to the left side of the umbilicus in this form ( {> ). Hav- 
ing divided the linea alba, I made a small aperture into 
the peritoneum, and introduced my finger into the abdo 
Voi . II. I i 



242 ELEMENTS OF SURGERY. 

men ; and then, with a probe-pointed bistoury, enlarged 
the opening into the peritoneum to nearly the same ex- 
tent as that of the external wound. Neither the omen- 
tum nor intestines protruded ; and during the progress 
of the operation, only one small convolution projected 
beyond the wound. 

" Having made a sufficient opening to admit my finger 
into the abdomen, I then passed it between the intes- 
tines to the spine, and felt the aorta greatly enlarged, 
and beating with excessive force. By means of my fin- 
ger nail, I scratched through the peritoneum on the left 
side of the aorta, and then gently moving my finger from 
side to side, gradually passed it between the aorta and 
spine, and again penetrated the peritoneum on the right 
side of the aorta. 

" I had now my finger under the artery, and by its 
side, I conveyed the blunt aneurismal needle armed with 
a single ligature behind it ; and my apprentice, Mr. Key, 
drew the ligature from the eye of the needle to the ex- 
ternal wound ; after which the needle was immediately 
withdrawn. 

" The next circumstance, which required considerable 
care, was the exclusion of the intestine from the ligature, 
the ends of which were brought together at the wound, 
and the finger was carried down between them, so as to 
remove every portion of the intestine from between the 
threads : the ligature was then tied, and its ends were 
left hanging from the wound. The omentum was drawn 
behind the opening as far as the ligature would admit, 
so as to facilitate adhesion ; and the edges of the wound 
were brought together by means of a quilled suture and 
adhesive plaster. 

" During the time of the operation, the feces passed 
off involuntarily, and the patient's pulse, both immedi- 
ately, and for an hour after the operation, was 144 in a 
minute ; he was ordered thirty drops of tincture of opium 



ELEMENTS OF SURGERY. 248 

and camphorated mixture, and the involuntary discharge 
of fasces soon after ceased. 1 applied my hand to his 
right thigh immediately after the operation, and he said 
that I touched his foot ; so that the sensibility of that 
leg was very imperfect. 

"For the following particulars I am indebted to Mr. 
Cox, one of my apprentices. 

"At midnight his pulse was 132. 

" 26. — At one o'clock in the morning, the patient 
complained of heat in the abdomen, but he felt no pain 
upon pressure ; he said that his head felt hot, and that 
he had pain in the shoulders ; his lower extremities, 
which were cold soon after the operation, were now re- 
gaining their heat ; his body was in other parts covered 
with a cold sweat. The sensibility of the lower extre- 
mities has been very indistinct since the operation. 

" At 2 o'clock, he felt so comfortable from his medi- 
cine that he wished to have more of it, and ten drops of 
tincture of opium were given him ; his legs were wrap- 
ped in flannel, bottles of hot water were applied to the 
feet, and he then said that the heat of his belly was 
lessened. 

" At 6 o'clock the sensibility of his limbs was still 
imperfect. 

" At 8 o'clock A.M. he expressed himself as feeling 
<|uite comfortable ; he however passed no urine, and had 
no evacuation ; his right limb was warmer than the left, 
and the sensibility was returning. 

" At noon the temperature of the right limb was 94, 
that of the left or aneurismal limb 87 f . 

" At 1 o'clock P.M. Mr. Cooper visited him, and as 
he walked up the ward he appeared much gratified at 
seeing his patient, who was at the point of death the 
evening before, and who was now adjusting his bed- 
clothes, and smiled as Mr. C. approached his bed. 

"At 3 o'clock after a fit of coughing, the man was 



244 ELEMENTS OF SURGERY. 

much alarmed with the idea of the thread having slipped 
into the wound : it was a false alarm ; hut, to prevent 
the idea of its occurrence, it was fastened to a quill : 
soon after this he complained of pain in the ahdomen 5 
it was not very severe, nor did it last long ; readily 
yielding to fomentations. As he had no evacuations, he 
was ordered an enema. 

" At 6 o'clock, P.M. he vomited, soon after the glys- 
ter had been administered : the heat of the right leg was 
96, that of the left or diseased limb 87 1. 

« At nine in the evening he took half a glass of port 
wine in warm water, which he immediately rejected : 
he complained of pain in the loins; his pulse was 104 
and feeble ; he was very restless, and had an involun- 
tary discharge of fasces. 

" Eleven at night, his pulse 100 and weak ; he still 
vomited. 

" 27. — At 7 A.M. th/ report was, that he had passed 
a restless night ; the vomiting had returned at intervals ; 
his pulse 104, weak and fluttering ; he complained of 
pain all over his body, more particularly in his head ; 
and the carotids beat with considerable force ; he had 
great anxiety expressed in the countenance, was very 
restless, and the urine dribbled from him, with some 
degree of pain at the end of the penis. 

" At 8 o'clock, A.M. the aneurismal limb appeared 
livid and felt cold, more particularly around the aneu- 
rism, but the right leg remained warm. 

"At 11 o'clock his pulse was 120 and weak ; he ap- 
peared to be sinking. To the questions which were put 
to him he did not return any answer ; he appeared to 
have an uneasiness about the heart as he kept his hand 
upon the left breast. 

" He died at 18 minutes after one, P.M. having sur- 
vived the operation 40 hours. 

" After being informed of his death, I requested Mr. 



ELEMENTS OF SURGERY. 245 

Brookes of Blenheim Street to attend with me at the 
inspection of the body. Mr. Travers, surgeon of St. 
Thomas's Hospital, Mr. Stoeker, apothecary of Guy's, 
and a large concourse of medical students attended the 
examination. 

" When the abdomen was opened, we found not the 
least appearance of peritoneal inflammation, excepting 
at the edges of the wound. The omentum and intes- 
tines were free from any unnatural colour ; the edges of 
the wound were glued together by adhesive inflamma- 
tion, excepting at the part at which the ligature project- 
ed. We were much gratified to find that the ligature 
had not included any portion either of the omentum or 
intestine : the thread had been passed around the aorta 
about | of an inch above its bifurcation, and about an 
inch or rather more below the part at which the duode- 
num crossed the artery. Upon carefully cutting open 
the aorta, a clot of more than an inch in extent was 
found to have sealed the vessel above the ligature ; be- 
low the bifurcation, another, an inch in extent, occupied 
the right iliac artery, and the left was sealed by a third 
which extended as far as the aneurism ; all were grati- 
fied to observe the artery so completely shut in 40 hours. 
The aneurismal sac, which was of a most enormous size, 
reached from the common iliac artery to below Poupart'g 
ligament, and extended to the outer side of the thigh. 
The artery was deficient from the upper to the lower 
part of the sac, which was occupied by an immense 
quantity of coagulum. 

" The neck of the thigh-bone had been broken within 
the capsular ligament, and had not been united. 

" Upon consideration of all the circumstances of the 
case, to what are we to attribute this man's death ? It 
did not arise from inflammation, for the viscera of the 
abdomen were perfectly free from it. 



246 ELEMENTS OF SURGERY. 

" His death appears to me to have been owing to want 
of circulation in the aneurismal limb ; for although the 
warmth of the other limb was preserved, that on which 
the aneurism was seated never gained its natural heat, 
which must have arisen from the great bulk of the aneu- 
rism, and from the disturbed state of the coagulum which 
it contained, which would prevent the free course of the 
blood through the aneurismal sac. That limb never re- 
covered its natural heat, there being seven degrees dif- 
ference between the two extremities ; the sensibility also 
i:i the right limb was returning, which did not appear 
to be the case in the left. In an aneurism therefore 
similarly situated, the ligature must be applied before 
the swelling has acquired any very considerable magni- 
tude. 

" There is still a circumstance, however, that remains 
to be decided respecting a ligature upon the aorta ; which 
is, in what manner it is to be afterwards separated : 
whether it should be left suspended at the wound, or 
cut oft' close to the vessel : whether the presse-arte re of 
that ingenious surgeon Mr. Crampton should be employ- 
ed ; or some unusual material should be used as a liga- 
ture. Although the patient whose case I have here given, 
did not suffer from inflammation of the abdomen, yet I 
should much fear that if he had lived longer, an extra- 
neous substance suspended amidst the intestines would 
have produced that effect. 

" My friend Mr. Lawrence has proposed that the 
silk usually employed for ligatures should be cut off 
close to the knot, so as to heal the wound over it. It has 
occurred to me that catgut would answer the purpose 
better, and I shall give the result of the trial which I 
have made, wishing it to be understood that I consider 
the subject at present as undecided, and only as one for 
future investigation. 

" Catgut, employed as a ligature, being more of the 



ELEMENTS OF SURGERY. 247 

mature of the animal matter in which it is embedded. 
will be more easily absorbed than silk ; or, if even not 
absorbed, will be less likely to excite irritation in the 
parts. 

" I have reason to hope that the following case will 
be considered as highly interesting and important, as the 
operation was performed upon a person so advanced in 
life as to lessen the hope which would have arisen from 
the more usual operation for aneurism. 

" I performed the operation at Guy's Hospital, where 
the patient, who is the subject of it, at present remains ; 
the notes of the case were taken by Mr. Hey, the son 
and grandson of the celebrated practitioners of that name 
at Leeds, who is now my pupil and clerk at Guy's Hos- 
pital. From the assiduity he has discovered in his stu- 
dies, and the acquirements made in his profession, there 
is every probability that he will confer additional bril- 
liancy on a name which ranks amongst the highest in the 
present race of the medical profession. 

CASE. 

" October 15th, 1817, William Heydon, aged 80, of 
a spare habit, but enjoying good health, has been for 
some years without any regular employment on account 
of his age, but accustomed to take more or less of walk- 
ing excercise ; his habits of life have been always regu- 
lar. About three months ago he perceived a pulsating 
tumour situated very low down in the ham, and which 
at that time was about the size of a pullet's egg ; he 
could assign no cause for its appearance, and took but 
little notice of it. In a few weeks, however, it increa- 
sed so much in size, and the pulsation became so strong, 
that he was induced to shew it to a surgeon, who, find- 
ing it to be an aneurism, recommended him to come into 
the hospital. 



248 ELEMENTS OF SURGERY. 

" The tumour was now larger than an egg, compres- 
sible, the pulsation very strong and perceptible, and the 
skin of a natural colour. The pulse, though slow and 
not weak, intermitted : and the pulsation in the tumour 
exactly corresponded with it. He complained of a con- 
siderable pain in the leg at times, and when the pain 
was most violent the leg was very much swelled. The 
motion of the joint was somewhat impeded. 

(i 24. — The usual incision for popliteal aneurism was 
made, and a single ligature was applied round the arte- 
ry, both ends of which were cut off close, and the edges 
of the wound brought together by adhesive plaster : the 
substance made use of for the ligature was catgut, which 
had been previously soaked in water, about the tempera- 
ture of 100°. The coats of the artery were very much 
relaxed, so as to occasion some difficulty in passing the 
ligature round it. 

■" 5 1 P.M. About four hours after the operation, com- 
plained of a sense of colduess and uneasiness in the limb 
which had been operated on ; its temperature was 80°, 
and that of the sound limb 84°. The pulse which beat 
76 times in the minute was full and very irregular, but 
did not intermit. 

" 25. — Has not passed a very good night, but feels 
comfortable this morning. Temperature of the limb 
that has been operated on 84 y , that of the sound limb 
92° ; pulse 60, and intermits ; but very rarely. 

" 26. — Has had a good night, and feels more com- 
fortable, though he still complains of violent pain in his 
leg at times ; temperature of the affected limb 89°, that 
of the sound limb 92° ; pulse intermits once in every 10 
or 12 beats. 

"27. — Much in the same state as yesterday; tem- 
perature of the affected limb 89°, sound limb 87°. 

" 28. — The wound was dressed for the first time 
since the operation, and was found to be completely 



ELEMENTS OF SURGERY. 249 

united ; the pulse varies very much in its intermissions, 
but upon the whole they have been much less frequent 
since than before the operation. 

" 29. — Temperature of the affected limb 89°, sound 
limb 87°. 

" 30. — Temperature of the affected limb 89°, sound 
limb 93° ; the tumour in the ham is considerably lessen- 
ed and has no pulsation ; nor is any pulsation to be yet 
felt in the anterior or posterior tibial artery, though a 
free circulation appears to be carried on in the super- 
ficial veins. 

" 3 1 . — Temperature of the affected limb 90°, sound 
limb 91°. 

" November 1. — Temperature of the affected limb 91°, 
sound limb 91°. 

"7. — Nothing material has occurred since the last 
report ; there has been very little variation in the tem- 
perature of the limb, or in the state of the aneurismal 
tumour, which continues gradually to subside. The 
wound remains perfectly united and free from irrita- 
tion. 

" 15. — The tumour continues to diminish in size and 
is much softer ; no pulsation can yet be felt in the ante- 
rior or posterior tibial artery : his health is very good, 
and he can walk about the ward with the assistance of 
a crutch. 

" 21. — Continues to improve, no appearance of irrita- 
tion from the ligatures ; no pulsation in the anterior or 
posterior tibial artery. 

" In three weeks after the operation he walked in the 
ward wilh the aid of a crutch, and in the first week, he 
had no other complaint than coldness in the foot on that 
side, with some pain in the heel. 

"December 17. — His health is perfectly good; he 
walks without the aid of crutch or stick ; the swelling 
Vol. 11 Kk 



250 ELEMENTS OF SURGERY. 

is re duced to a small size ; and the part at which the 
incision was made has been and now is quite free from 
irritation. 

" I confess that this case gave me much pleasure ; the 
great age of the patient, the simplicity of the operation, 
the absence of constitutional irritation and consequently 
of danger, and his rapid recovery, lead me to hope that 
the operation for aueurism may become at some future 
period, infinitely more simple than it has been rendered 
to the present moment." 



ELEMENTS OF SURGERY. 251 

CHAPTER XXVIII. 

Of False Aneurisms. 

Spurious or false aneurisms are always occasioned by 
a wound or rupture of an artery, in consequeuce of which 
blood escapes out of the cavity of the artery and forms 
an aneurismal sac in the surrounding parts. The term 
diffused false aneurism is applied to those case« where 
the blood forms an irregular swelling extending in dif- 
ferent directions from the seat of the injury, and the 
aneurism is called circumscribed, when a regular, cir- 
cumscribed tumour is formed. These terms are applied 
also in some cases to true aneurisms without any pro- 
priety, since the extent of diseased vessel does not occa- 
sion any change in its nature. 

A species of false aneurism called varicose was first 
described by Dr. William Hunter.* In this disease the 
coats of an artery are punctured by an instrument which 
had previously passed through a neighbouring vein, and 
by this means corresponding apertures are formed where- 
by the blood flows out of the artery into the vein. The 
accident generally happens in the common operation of 
venesection. 

Dr. Hunter's account of this affection is very accurate. 
" In the operation of bleeding, the lancet is plunged into 
the artery through both sides of the vein, and there will 
be three wounds made in these vessels, viz. two in the 
vein and one in the artery, and these will be nearly op- 
posite to one another, and to the wound in the skin. 
This is what all surgeons know has happened in bleed- 

* Scarpa says by Guattani. 



252 ELEMENTS OF SURGERY. 

ing, and the injury done the artery is commonly k noun 
by the jerking impetuosity of the stream, whilst it flows 
from the vein, and by the difficulty of stopping it, when 
a sufficient quantity is drawn. 

" In the next place we must suppose, that the wound 
of the skin, and of the adjacent, or upper side of the 
vein, heal up as usual ; but, that the wound of the artery, 
and of the adjacent, or under side of the vein, remain 
open (as the wound of the artery does in the spurious 
aneurism) and, by that means, the blood is thrown from 
the trunk of the artery, directly into the trunk of the 
vein. Extraordinary as this supposition may appear, in 
reality it differs from the common spurious aneurism in 
one circumstance only, viz. the wound remaining open 
in the side of the vein, as well as in the side of the arte- 
ry. But this one circumstance will occasion a great 
deal of difference in the symptoms, in the tendency of the 
complaint, and in the proper method of treating it: upon 
which account the knowledge of such a case will be of 
importance in surgery. 

" It will differ in its symptoms from the common spu- 
rious aneurism principally thus. The vein will be di- 
lated, or become varicose, and it will have a pulsating 
jarring motion on account of the stream from the artery. 
It will make a hissing noise, which will be found to cor- 
respond with the pulse for the same reason. The blood 
of the tumour will be altogether, or almost entirely fluid, 
because kept in constant motion. The artery, I appre- 
hend, will become larger in the arm, and smaller at the 
wrist, than it was in the natural state ; which will be 
found out by comparing the size, and the pulse of the 
artery in both arms, at these different places ; the rea- 
son of which I shall speak of hereafter. And the effects 
of ligatures, and of pressure upon the vessels above the 
elbow and below it, will be what every person may rea- 



ELEMENTS OF SURGERY. 258 

tlily conceive, who understands any thing of arteries and 
veins in the living body. 

" The natural tendency of such a complaint will be 
very different from that of the spurious aneurism. The 
one is growing worse every hour, because of the resist- 
ance to the arterial blood, and if not remedied by surge- 
ry must at last burst, the other in a short time comes to 
a nearly permanent state ; and, if not disturbed, produces 
Uo mischief, because there is no considerable resistance 
to the blood, that is forced out of the artery. 

" The proper treatment must, therefore be very dif- 
ferent in these two cases, the spurious aneurism requir- 
ing chirurgical assistance, as much, perhaps, as any dis- 
ease whatever; whereas, in the other case, I presume 
it will be best to do nothing. 

" If such cases do happen, they will no doubt be found 
to differ among themselves, in many little circumstances, 
and particularly in the shape, &c. of the tumefied parts. 
Thus the dilatation of the veins may be in one only, or 
in several, and may extend lower or higher in one case, 
than in another, &c. according to the manner of branch- 
ing, and to the state of the valves in different arms. And 
the dilatation of the veins may also vary, on account of 
the size of the artery that is wounded, and of the size of 
the orifice in the artery and in the vein. 

u Another difference in such cases will arise from the 
different manner, in which the orifice of the artery may 
be united or continued with the orifice of the vein. In 
one case, the trunk of the vein may keep close to the 
trunk of the artery, and the very thin stratum of cellular 
membrane between them, may by means of a little in- 
flammation and coagulation of the blood among its fila- 
ments, as it were, solder the two orifices of these vessels 
together, so that there shall be nothing like a canal going 
from one to the other ; and then the whole tumefaction 
will be more regular, and more evidently a dilatation of 



254 ELEMENTS OF SURGERY. 

the veins only. In other instances the blood that rushes 
from the wounded artery, meeting with some difficulty 
of admission and passage through the vein, may dilate 
the cellular membrane, between the artery and vein, into 
a bag, as in a common spurious aneurism,, and so make 
a sort of canal between these two vessels. The trunk 
of the vein will then be removed to some distance from 
the trunk of the artery, and the bag will be situated 
chiefly upon the uuder side of the vein. The bag may 
take an irregular form, from the cellular membrane 
being more loose and yielding, at one place, than at 
another, and from being unequally bound down by the 
fascia of the biceps muscle. And if the bag be very 
large, especially if it be of an irregular figure, no doubt, 
coagulations of blood may be formed, as in the common 
spurious aneurism." 

With respect to the treatment of false aneurism, no 
reliance is to be placed upon any remedy except the li- 
gature ; a free incision is to be made into the cavity of 
the aneurism, that the bleeding orifice may be seen or 
felt : a ligature is then to be applied above and another 
below it, and firmly tied. One of the most serious 
cases of this kind is a case of aneurism recorded by Mr. 
John Bell. The injury was occasioned by a fall on a 
pair of scissors which penetrated the hip opposite the 
sciatic notch ; an aneurismal tumour formed, an in- 
cision was made into it, and a large quantity of coagu- 
lated blood was suddenly discharged. The opening was 
enlarged and the clots evacuated. A torrent of fresh ar- 
terial blood now jetted forth, and " in a moment twenty 
hands were about the tumour and the bag was filled 
with sponges and cloths of all kinds." At this instant 
a bistoury was run upwards and downwards, and an in- 
cision two feet in length was made, at which time the 
patient was apparently lifeless. Mr. Bell now disco- 



ELEMENTS OF SURGERY. 255 

vered with his finger the gush of warm blood, and dis- 
tinctly felt the pulsation of the vessel, which convinced 
him that the man was still alive. The artery was easily 
secured ; it was the posterior iliac artery which had been 
cut fairly across, and bled with open mouth ; it was cut 
and tied exactly where it turns over the bone. The pa- 
tient ultimately recovered. 

In all such cases it is of primary importance to act 
with promptness and decision; delay in such cases is 
not merely dangerous but fatal. In all operations, there- 
fore, for the cure of false aneurism, if practicable, the 
loss of blood should be restrained by a tourniquet, or 
pressure, on the artery supplying the tumour, whilst the 
operation is performed, and in such cases the surgeon 
may act deliberately ; but where cases occur similar to 
that described by the dauntless surgeon last quoted, a 
bold and sudden exertion is absolutely indispensable. 
Mr. Bell's rules of practice on this subject are so very 
important that 1 shall quote them from Dr. Smith's va- 
luable abridgement of his principles of surgery, and I 
know no part of Mr. Bell's writings more honourable to 
the author than his remarks on the present subject. 

" In great aneurisms, then, of the arm or thigh, when 
the tourniquet can be applied, do your operation delibe- 
rately, steadily, slowly, but do not needlessly prolong 
your patient's suffering. Cut the skin nicely, open the 
sac freely, dissect your artery very clean, and tie it clear 
of the nerve, and pass your ligature with a blunt needk 
or crooked probe ; for whenever you are reduced to the 
necessity of using the sharp needles your patient is in 
danger. Tie your artery with moderate firmness ; tie it 
in two places (for on several occasions the retrograde 
blood has flowed out even in the time of the operation ;) 
clean the sac ; look now attentively to your two liga- 
tures, and if you see the upper one moving according to 
the pulsation of the artery, all is right. Finally, if you 



256 ELEMENTS OF SURGERY. 

approve of my reasoning, cut the artery across in the 
middle betwixt the ligatures. When the tourniquet can- 
not be applied, do not trust to compression. Your as- 
sistant may try to compress the artery, but do not lay 
your account with performing a cool deliberate opera- 
tion ; expect rather a dash of blood at the first stroke you 
make into the sac, and confusion and alarm of every 
kind. Compose your mind for such a scene ; bend up 
each corporeal agent to this attempt ; expect safety for 
your patient from nothing but your own daring opera- 
tion ; be resolute, bold, and rapid; but let this boldness 
be the result of serious deliberation, and earnest consul- 
tation with your friends. And in what does this rapi- 
dity consist? Is it a dangerous stroke that you are to 
make ? No surely : the rapid movement is merely slit- 
ting up suddenly the half putrid and tendinous sac, and 
turning out the clots of blood with your fingers, while 
the artery, nerve, and all the important parts lie safe at 
the bottom of the tumour. You are to trust much to your 
acquaintance with the parts, therefore make sure of your 
knowledge of the artery that is actually wounded ; return 
to your books, drawings, and preparations ; hold consul- 
tations with your friends ; lose no opportunity of making 
up your mind beforehand ; the more you reason upon the 
case, and revolve the possible dangers, the greater will 
be your prospect of sustaining yourself with becoming 
resolution in the moment of operation." 

Dr. Smith very judiciously adds to these directions 
that " there is no necessity for opening the aneurismal 
sac in those cases in which you can tie the vessel above 
where it has been wounded, unless the sac is very large ; 
operate, in short, as in spontaneous aneurism." 

The treatment of varicose aneurism depends upon the 
nature of the case. In a great majority of instances the 
aneurismal sac is formed by the vein dilated into a pouch 



ELEMENTS OF SURGERY. 257 

over the artery. These cases sometimes occasion very 
little trouble to persons who do not use the arm violent- 
ly. Scarpa recommends in such cases to order the pa- 
tient to abstain from using the arm, and to keep it as 
little as possible hanging by the side. Perhaps mode- 
rate compression, absolute rest, and a low diet, would 
tend greatly to prevent mischief after the puncture of an 
artery, and in the forming state of varicose aneurism. 
In some instances a spontaneous cure takes place, and in 
others the disease remains without occasioning any great 
inconvenience. A whizzing noise can be heard by ap- 
plying the ear to the part, and any thing which excites 
the circulation occasions a distressing throbbing, but no 
tumour forms, and the patient prefers the existing evil 
to an operation. Mr. Pott, Dr. Hunter, and several 
other surgeons have met with such cases, and a lady of 
Philadelphia is at present situated in this manner. She 
has a varicose aneurism which was occasioned by vene- 
section many years ago, and it remains at present with- 
out occasioning any inconvenience sufficient to induce 
her to submit to an operation. 

In some few cases, however, a very different result 
takes place, and the vein becomes distended, producing 
all the dangers and most of the symptoms of other aneu- 
rismal swellings. In such instances the tumour must be 
cut open and treated as a common false aneurism, the 
aperture in the artery being secured by a ligature above 
and another below the orifice. To obviate all inconve- 
nience it is surely best as soon as au artery is known to 
have been opened in the operation of venesection to cut 
down to and tie it up. 

Dr. Hunter in his accurate description of varicose 
aneurism, or as it is now called aneukismal varix an- 
ticipated the probable occurrence of a case which he 
never saw, but which has since occurred to Mr. Park of 
Liverpool, and to Dr. Physick. 1 have marked in italics 
Vol. H. L 1 



258 ELEMENTS OF SVRGEUY. 

the words in which he hints at this case.* and I now pro 
cecd to detail such a one ; it was published by Dr. Phy- 
sick in the first volume of the Medical Museum together 
with the mode of treatment. 

" A young gentleman from Virginia applied to me 
last April to undertake the treatment of an aneurism, si- 
tuated at the bend of the elbow, occasioned by his having 
been bled in the basilic vein in October, 1801. He in- 
formed me that the bleeder at the time of the operation 
experienced no difficulty in stopping the blood, but that 
a very considerable ecehymosis formed, occasioning a 
livid colour of the skin about the wound and extending 
both above and below the elbow. The ecchymosis dis- 
appeared after a few days, but a pulsating tumour was 
observed directly under that part of the vein which had 
been punctured. This tumour gradually increased in 
size for six months, but afterwards the increase of the 
tumour, if any, was so slow as not to be observed, though 
the basilic vein running over it began to enlarge. 

" On examining the arm I found a tumour at the bend 
of the elbow pulsating very strongly ; exactly resembling 
a true aneurism : there was also two tumours, one si- 
tuated above, and the other immediately below this aneu- 
rysmal sac, in which the particular thrill always met 
with iu varicose aneurisms was very distinctly felt. 
These tumours were evidently distensions of the basilic 
vein, the trunk of which however for about three-fourths 
of an inch, where it passed over the aneurismal sac, was 
very little enlarged : by making pressure on the middle 
of this last mentioned portion of the vein, the orifice of 
communication between the aneurismal sac and the vein 
could be felt ; and by applying the finger accurately over 
it, the flow of blood into the vein could be prevented, 
and the thrill, while the pressure was continued, ceased. 
» The case was now easily understood : the artery had 

• < £4. 



ELEMENTS OF SURGERY. 259 

no doubt been punctured by the lancet, pushed into it 
through the vein by the bleeder : the pulsating tumour 
was a sac formed in the cellular membrane between the 
artery and vein, by the impulse of the arterial blood : the 
enlargement of this sac went on until its sides became 
firm and resisting, ahd then the blood from the sac was 
thrown with such force into the vein through the punc- 
ture in its lower side, as to cause it to distend very con- 
siderably, for two or three inches above and below the 
sac; the intermediate portion of the vein however run- 
ning over the sac being supported by it, was very little 
enlarged. 

" As the upper portion of the vein was observed to 
distend very rapidly, the skin covering it being very 
thin and every where marked with cicatrices ; the pa- 
tient apprehending a sudden rupture of the tumour, be- 
came very uneasy in his mind : the fore-arm was much 
diminished in size, and the hand was constantly cold. 
These circumstances together with the existence of the 
aneurismal sac, determined Dr. Wistar and my self to 
advise the operation of tying the artery above and below 
the sac. 

"I performed the operation in April, 180-1; within a 
quarter of an hour after, the pulse of the artery at the 
wrist was distinctly perceived ; in three weeks the wound 
was cicatrized, and the patient very soon recovered the 
most perfect use of his hand and arm. It seems unneces- 
sary to describe the operation further tiuTn to mention, 
that after dividing the skin and cellular membrane cover- 
ing the swelling by a straight incision, 1 dissected round 
the tumours, then tied the trunk of the vein above and 
below its enlargement, next tied the artery above and 
below the sac ; the parts comprehended between the 
ligatures were then cut out, which iias enabled me to 
have the annexed drawing of them made. They are. 
represented of their natural ^ize. 



260 ELEMENTS OF SURGERY. 



EXPLANATION OF THE PLATE. 



Fisr. 1. AA. The basilic vein distended above and be- 



*&• 



low the puncture. 



B. The cicatrix from bleeding. 
D. The aneurysmal sac. 
CC. The brachial artery. 

Fig. 2. AA. The enlarged vein. 

e. Orifice of communication between the vein 
and aneurismal sac. 

D. The inside of the aneurismal sac every where 
incrusted with bone. 

E. The orifice of communication between the 
artery and the aneurismal sac. 

CC. The brachial artery. 

F. Dotted lines representing the situation of the 
artery under the sac. The artery was not 
enlarged nor in any respect diseased. 



/'/..i/A- xxmi 



Fi<; / 




/•;;,- 




ELEMENTS OF SURGERY. 261 

I have lately seen a case of aneuvismal varix attended 
with some very extraordinary circumstances. The pa- 
tient had received many years before a load of buckshot 
in his leg. When the parts healed a varicose aneurism 
was discovered just below the knee, and in a short time 
the superficial veins of the leg were all enlarged, and the 
thrill peculiar to this species of aneurism could be dis- 
tinctly felt. When I saw the patient, twelve years had 
elapsed after the occurrence of the accident, and the 
veins of the leg from the toes to the groin were all great- 
ly distended. The leg was constantly very painful, and 
ulcers formed on the foot and ankle which resisted every 
remedy. 

The patient was attended by Dr. Physick and Dr. 
Wistar. The enormous distention of the vessels of the 
leg, and the uncertainty of finding the communication 
between the artery and vein induced them to tie up the 
femoral artery in the middle of the thigh. The patient's 
leg mortified as high up as the middle, and whilst the 
dead parts were separating a sudden and unexpected 
hemorrhage took place from one of the enlarged veins in 
the mortified part near the ankle, which greatly reduced 
his strength, and although the bleeding was for a time 
arrested by tying up the vein from which it issued, yet 
it recurred, unnoticed by the nurse, and he became gra- 
dually weaker and finally expired ; I dissected the limb 
and found the whole trunk of the femoral artery as high 
as the groin in an enlarged and unnatural state — the 
veins of the limb were all greatly distended, and a bougie 
readily passed along the popliteal artery into the poste- 
rior tibial artery, which was enlarged, and out of this into 
venous pouch situated at the inner part of the leg below 
the knee. 

Before concluding the subject of aneurism I shall 
briefly notice a species of tumour consisting chiefly of en- 



262 ELEMENTS OF SURGERY. 

larged blood-vessels, which has been called by Mr. John 

Bell, ANEURISM FROM ANASTOMOSIS. 

This complaint exists in some cases of nsevi materni 
in children, and is congenital. Many cases however 
occur in which a gradual enlargement of vessels takes 
place, originating in a pimple or spot, and sometimes 
appears to result from accidental injury. It is attended 
with constant throbbing, and great turgescence of the 
vessels, augmented and diminished in proportion to the 
rapidity of the general circulation. When the part hap- 
pens to be scratched hemorrhage takes place very freely 
from it, and sometimes the vessels burst without any ac- 
cidental injury and pour forth very considerable quanti 
ties of blood. 

There is but one remedy for this complaint ; the total 
excision of the diseased parts. It is very important 
to cut completely outside of the tumour; if the sur- 
geon inadvertently cut into it, the bleeding will be pro- 
fuse. The arteries which nourish the tumour are easily 
taken up, if the external incision is made at a small dis- 
tance from its margin. This is one of those cases in 
which it is important to remove the parts quickly, as the 
hemorrhage continues, and is sometimes very profuse 
during the operation. 

A very common situation for these tumours is the 
scalp, and no difficulty attends their extirpation. An in- 
cision should be made quickly round the swelling down 
to the bone, and then the diseased portion of scalp is 
easily detached, and the arteries which supplied it can 
be secured. 

Mr. Pelletan relates a case somewhat analogous to 
this disease, in which all the brandies of the temporal 
artery were morbidly dilated, and I have very recently 
seen a case of aneurismal tumour in which the whole 
scalp was pervaded by very large arteries. The princi- 



ELEMENTS OF S.URGERY. 263 

pal diseased spot, however, appeared to be formed of a 
convolution of the branches of the occipital artery. In 
this case the larger arteries leading to the tumour, some 
of which were equal in diameter to the brachial, were 
successively tied up before any operation was attempted 
on the tumour, and very fortunately, for notwithstanding 
this precaution, when the circular incision was made 
round the tumour, so large a quantity of blood was lost 
that great alarm was occasioned. 

To prevent the deformity attending the separation of 
large portions of scalp, Dr. Physick has in some cases 
cut round the tumour, tied up the blood-vessels, and suf- 
fered the parts to remain ; lint being interposed between 
the edges of the wound to prevent immediate union. The 
tumour after such an operation is in great measure ab- 
sorbed and much diminished in size. 

A very excellent account of these vascular tumours 
may be found in John Bell's Principles of Surgery. 



264 ELEMENTS OF SURGERY, 



CHAPTER XXIX. 



Of Mammary Abscess. 

The breasts of women are sometimes the seat of 
very painful and distressing abscesses. They are some- 
times seated deeply in the glandular substance of the 
breast, and at other times in the investing cellular mem- 
brane. The inflammation commences in the usual man- 
ner, and the pain, hardness, and swelling, are in gene- 
ral very considerable. 

When the glandular structure is affected the secretion 
of milk is much diminished, and is sometimes totally 
suspended. The disease in its progress is attended with 
severe pains shooting up into the axilla, and the axil- 
lary glands often swell and inflame. 

The progress of this complaint varies ; sometimes it 
is rapid and suppuration takes place in three or four 
days, and in other cases it is much slower. Sometimes 
an cedeinatous swelling forms, and the nipple appears 
buried below the level of the skin. In some cases seve- 
ral distinct hard tumours are found in the breast ; and 
when these suppurate an equal number of separate ab- 
scesses are formed. It now and then happens that one 
abscess opens by several small apertures, and sinuses 
are thus made, communicating with each other under 
the skin. 

Mammary abscesses form at different periods after de- 
livery, and are always attended with more or less fever 
preceded in general by a chilly fit. They result some- 
times from exposure to cold-from tight dresses-acci- 
dental injuries-long retention of milk-and from the 



ELEMENTS OF SURGERY. 265 

usual causes of inflammation ; and in other instances no 
evident cause can be assigned. 

The remedies for this complaint differ in nothing from, 
the common remedies for inflammation. Blood-letting 
according to the strength of the patieut, purges, and low 
diet are to be first employed. After general bleeding the 
application of leeches is extremely serviceable. The 
best local remedy is a soft bread and milk 
with lead water. After the use of the preceding reme- 
dies, if the inflammation continue, a blister should be 
applied over the inflamed part. 

Wheal suppuration is established if the abscess should 
not speedily open, a puncture may be made with a lancet, 
and the matter evacuated ; free incisions have been recom- 
mended in these cases, but during the existence of acute 
inliammation they are unnecessary, and the puncture can 
in general be kept from healing by a soft poultice, or by 
a piece of linen rag placed in the orifice. 

When sinuses form they are to be laid open freely. 
When an cedamatous swelling takes place the application 
of spiritus mindereri, and repeated purges generally carry 
it off. The indurations which sometimes follow mam- 
mary abscess have been already noticed in the chapter 
on cancer ; they yield in general to purges, blisters, mer- 
cury, and cicuta. 



Vol. II. M m 



266 ELEMENTS OF SURGERY- 

CHAPTER XXX. 

Abscess of the Hip Joint. 

This is a well known disease met with in patients of 
every age, but more commonly in children than in adults. 
In its commencement it is very insidious, and sometimes 
is not preceded by any pain ; a slight weakness, and 
some degree of limping generally attend ; a loss of ap- 
petite, and disinclination to motion are observed. A pain 
in the knee is a common symptom ; and this pain some- 
times misleads patients and their medical attendants, 
who imagine the mischief to be seated in the knee, and 
have no suspicion of the hip. 

In general before the disease has made much pro- 
gress, pain is perceived in the vicinity of the affected 
joint, and the limb appears longer than the sound one — 
a circumstance easily accounted for from the crooked- 
ness of the pelvis, the patient supporting the weight of 
the body entirely upon the sound side, the limb becomes 
diminished and emaciated. Pain is experienced in exa- 
mining the limb, from pressure upon the parts concerned 
in forming the joint which are in a state of inflammation. 
The nates become flattened — the whole form and ap- 
pearance of the hip is changed, and the natural convexi- 
ty of the buttock is lost. The knee may be moved with- 
out pain, but every motion of the hip occasions a very 
severe pain. When the patient attempts to walk, the 
thigh is bent forwards, the knee is flexed, and the weight 
of the body is almost entirely sustained by the sound 
limb ; great pain is sometimes experienced in attempts to 



ELEMENTS OF SURGERY. 267 

straighten the affected limb. The preceding symptoms 
characterize the early stage of the complaint. 

When pus is about to form, the pain is augmented and 
becomes constant ; the soft parts around the joint be- 
come sore and tender ; a degree of tension is perceived ; 
the skin is hot and red, and considerable fever comes on, 
sometimes attended with fits of shivering. Shortly after 
these symptoms the pain abates, and a swelling is per- 
ceived containing pus. 

In some instances, however, the inflammation assumes 
a more chronic form, and no particular increase of pain 
precedes the formation of pus. 

It sometimes happens that after the affected limb has 
been longer than the sound one, it suddenly becomes 
shorter; this is owing to what has been ca\\e& & sponta- 
neous dislocation of the osfemoris ; the head of the bone 
is actually protruded from the acetabulum by the inflam- 
matory swelling of the contents of that cavity. It is said 
that this dislocation sometimes precedes the formation 
of pus. The joint then gets well without an abscess, 
and the parts heal by anchylosis ; but this is rare. 

Hectic fever generally attends the disease of the hip 
joint. Pus of a thin sanious consistence is continually 
discharged from one or more orifices. Abscesses form 
in various parts of the thigh, and the strength of the pa- 
tient is much exhausted. Carious bone can generally 
be felt by a probe passed into any of the sinuses. 

The acetabulum is diseased as well as the os femoris : 
the cartilages detached by absorption, and the solid bone 
is also greatly diminished by the same process. In some 
cases this separation of the cartilages gives rise to an 
anchylosis between the os femoris and acetabulum, and 
a cure is effected ; but more commonly the disease pro- 
gresses — every motion is attended with extreme pain 5 
the patient lingers months and even years, and ultimate- 
ly expires. 



268 ELEMENTS OF SURGERY. 

I have known the bottom of the accetabulum absorbed 
in a case of hip disease and the head of the os femoris 
pushed through into the pelvis. 

TREATMENT. 

The remedies to be successful must be active in the 
early stage of the complaint — but it unfortunately hap- 
pens that we are seldom sent for until the disease has 
made great progress ; bleeding, purging, emetics, sea 
bathing, the various remedies for scrofula, mercury and 
many others have been used in this disease without ef- 
fect — Issues which are highly recommended, do but 
little service — Dr. Physick has seen a great number of 
these cases, and has found those succeed best which 
were treated by very active and long continued purg- 
ing. The best cathartic is Jallap and Cream of Tartar 
every day, or every two days — the health and strength 
of the patient under this mode of treatment greatly im- 
proves, and in several instances a complete cure has 
been effected. In addition to this, however, a vegeta- 
ble diet, and absolute rest are to be enjoined. In chil- 
dren it is difficultto carry this last prescription into effect, 
aud it is found extremely convenient to have a curved 
splint to fit the hip and thigh. 

After suppuration comes on, little can be done, but 
to keep open the sinuses till the dead bone comes out. 
v The constitution must be supported by bark, wine, and 
nourishing diet — and inflammatory fever when it occurs, 
must be combatted by bleeding, and a low diet — Leech- 
es and blisters are certainly useful in the early stage of 
the disease. 

The appearances of a diseased hip joint on dissection 
vary according to the period of the disesse at which it is 
made. Mr. Ford gives an account of two dissections, 
one in an early and the other in a later stage of the co?a- 



ELEMENTS OF SURGERY. 269 

plaint. In the first the head of the os femoris wa ; in- 
flamed ; the capsular ligaments were somewhat thicken- 
ed, the round ligament retained its usual connection both 
to the head of the thigh bone, and to the acetabulum ; 
abour, a teaspoonful of pus was contained in the cavity 
of the joint, and the cartilage liniug the acetabulum was 
eroded (absorbed) in one place with a small aperture 
through which a probe might be passed underneath the 
cartilage into the internal surface of the os pubis on one 
side, and on the other into the os ischii, the opposite or 
external part of the os iuhominatum shewing more ap- 
pearance of disease than the acetabulum. In the second 
case the disease was more advanced, and exhibited the 
usual appearances of a destruction of parts in conse- 
quence of suppuration. 

The best writers on this subject are Desault, Boyer, 
Cooper, Crowther, and Ford. 

A disease somewhat analogous to that of the hip joint 
occurs in the knee, and forms one species of white swel- 
ling ; for a very excellent history of that subject, and 
v other affections of the joints, I refer to Mr. Sa- 
muel Cooper's valuable treatise on the diseases of the 
joints. 



270 ELEMENTS OF SURGERY. 



CHAPTER XXXI. 



Lumbar or Psoas Abscess. 

Of the various abscesses which fall under the notice 
of the surgeon, there is not one more extensive or se- 
rious than that which occurs in the loins, and which is 
therefore denominated lumbar abscess. The matter col- 
lected in these cases is seated in the cellular texture sur- 
rounding the psose muscles, and hence the disease is fre- 
quently called psoas abscess. These collections of mat- 
ter are situated posteriorly to the peritoneum, and occa- 
sion swellings in various situations. The disease origi- 
nates in many cases in bruises or hurts, but in a variety 
of instances no evident exciting cause precedes it, and 
it is ascribed to bruises in bed, slight sprains, or hea- 
vy lifts, &c. 

The symptoms often commence with a difficulty in 
walking, with some sense of weakness or uneasiness in 
the loins, but without any acute pain. Indeed we some- 
times find very copious collections of pus in these cases 
without any pain having preceded. 

The matter formed increases gradually in quantity, 
and makes its appearance by a tumour in the upper part 
of the thigh, or just under Pou part's ligament ; some- 
times it descends lower and points at the middle of the 
thigh, travelling under the tendinous fascia femoris ; 
sometimes in the loins, and sometimes on the back. It 
occasionally descends into the pelvis and points near 
the anus, resembling a fistula in ano. I once saw a case 
in which a gallon of pus was discharged from a psoas 
abscess which opened within an inch of the anus — my 



ELEMENTS OF SURGERY. 271 

patient very speedily and happily recovered his general 
health, though a fistula in ano was the consequence, and 
this was cured by an operation. 

Psoas abscess is often connected with a curious state 
of the vertebrae ; sometimes this caries is a cause and at 
other times an effect of the abscess. Where this is the 
case the patient is generally unable to stand erect, and 
to exert the muscles of the loins, and paralysis of the 
lower limbs comes on. 

Where the tumour appears in the groin it has been 
mistaken for hernia ; the tumour subsiding when the pa- 
tient is in a recumbent posture and returning again when 
he rises erect. The fluctuation being evident, removes 
any doubt of this kind. 

TREATMENT. 

When we are called early in the disease the usual re- 
medies for inflammation must be used ; bleeding, purg- 
ing, and low diet, leeches to the loins, or cupping, are 
also useful — Rest and a horizontal posture must be en- 
joined — Blisters over the lower part of the back are 
highly serviceable — Issues with caustic are to be resort- 
ed to if the previous remedies fail. 

After matter has formed and presented itself by an ex- 
ternal tumour, it becomes an object of very considerable 
moment to ascertain whether the abscess should be opened. 
We need not apprehend any danger of its opening into 
the cavity of the abdomen, as there are no such instan- 
ces recorded, although fatal hemorrhage has in some 
cases resulted from absorption of the great blood vessels 
in the vicinity of the abscess. 

T'he danger of opening the abscess depends upon the vio- 
lent fever which invariably follows a wound of any large 
cavity, unless the opening be healed immediately and the 
cavity be again rendered perfect. Mr. Hunter first taught 



272 ELEMENTS OF SURGERY. 

that the imperfection merely of a large cavity without its 
exposure to the air, would cause extensive inflammation 
through its sides, and violent constitutional effects. Mr, 
Abernethy to avoid the evils of an imperfect cavity, pro- 
2>osed to make a puncture through the parietes of the ab- 
scess in such a manner that the sides of the wound might 
heal by the first intention. This is effected by making a 
valvular opening with a sharp lancet, by passing the 
lancet first through the skin, and then obliquely upwards 
under the skin, for half an inch or more, then the point 
of the lancet is to be depressed and pushed iuto tke ca- 
vity of the abscess. The matter now Hows freely through 
the wound ; if the patient's strength permit, and the ab- 
scess be not very large, the whole contents may be at 
once removed : but in cases where large quantities of pus 
are collected this is dangerous ; we therefore remove a 
pint or more, and complete the evacuation a few hours 
after — the sides of the puncture are now to be brought 
into contact, and kept so by adhesive plaster — they unite 
readily. In performing this operation great care is ne- 
cessary, if the abscess, point in the groin, to avoid the 
large vessels — probes or cauulas are never to be intro- 
duced. After the operation the matter collects in a 
few weeks, and is to be again opened in the same man- 
ner. This operation repeated several times has the ef- 
fect of gradually contracting the dimensions of the cavi- 
ty, and when this is considerably diminished a larger 
opening may be made without danger. In some cases, 
however, the puncture does not heal by the first inten- 
tion, and then extensive inflammation supervenes, and 
often terminates fatally. 

The disease we are now considering is frequently at- 
tended with caries of the vertebrae (of which we shall 
speak more particularly in the next chapter.) In that 
case it becomes doubtful whether an opening ought to 
be made into the abscess for the evacuation of the pus. 



ELEMENTS OF SURGERY. 273 

because so long as carious bono exists in the spine, so 
long will suppuration continue, and consequently no rea- 
sonable hope of a cure can be entertained. If it be dis- 
tinctly ascertained that carious bone does exist, then I 
believe it will be best not to make a puncture into the 
cavity of the abscess, except there be danger of an open- 
ing by ulceration, in which case the puncture should at 
all events be made, because a very small aperture will 
be thereby substituted for a larger one, and much of the 
danger from inflammation in the cavity of the abscess 
will be prevented. The puncture should be healed as 
speedily as possible. The mode of treatment when ca- 
rious vertebras are discovered will be detailed presently. 
It is to be confessed, however, that we are not always 
able to ascertain when the vertebrae are in this state. 

Mr. Crowther has succeeded in curing some cases of 
lumbar abscess without puncturing, even after large col- 
lections of matter had formed ; his treatment consists in 
the repeated application of blisters over the integuments 
covering the abscess, which are to be kept open by savin 
cerate. 



Voi, IT. N n 



274 ELEMENTS OF SURGERY. 



CHAPTER XXXII. 



Of Curved Spine. 

By this name is designated a disease, or caries, of the 
vertebra;, which has long been familiar to surgeons, hut 
-was never well understood until the investigations of Mr. 
Pott rendered its nature intelligible. I shall therefore 
take the following observations from his excellent trea- 
tise on the subject. 

" The disease, of which I am to speak, is a disease 
of the Spine, producing an alteration in its natural 
figure, and not unfrequently attended with a partial, or 
a total loss of the power of using, or even of moving, 
the lower limbs. 

" From this last circumstance (the loss of the use of 
the limbs) it has in general been called a Palsy, and 
treated as a paralytic affection ; to which it is in almost 
every respect perfectly unlike. 

" The occasion of the mistake is palpable ; the patient 
is deprived of the use of his legs, and has a deformed 
incurvation of the spine ; the incurvation is supposed to 
be caused by a dislocation of the vertebrae ; the displaced 
bones are thought to make an unnatural pressure on the 
spinal marrow, and a pressure on that being very likely 
to produce a paralysis of some kind, the loss of the use 
of the legs is in this case determined to be such : the 
truth is, that there is no dislocation, no unnatural pres- 
* sure made on the spinal marrow, nor are the limbs by 

any means paralytic, as will appear to whoever will ex- 
amine the two complaints with any degree of attention. 



ELEMENTS OF SURGEUY. 275 

" 111 the true paralysis, from whatever cause, the mus- 
cles of the affected limb are soft, flabby, unresisting, 
and incapable of being put into even a tonic state ; the 
limb itself may be placed in almost any position or pos- 
ture ; if it be lifted up, and then let go, it falls down, 
and it is not in the power of the patient to prevent, or 
even to retard its fall : the joints are perfectly and easily 
moveable in any direction ; if the affection be of the 
lower limbs, neither hips, knees, nor ancles, have any 
degree of rigidity or stiffness, but permit the limb to be 
turned or twisted in almost any manner. 

" In the present case, the muscles are indeed extenu- 
ated, and lessened in size ; but they are rigid, and al- 
ways at least in a tonic state, by which the knees and 
ancles acquire a stiffness not very easy to overcome ; by 
means of this stiffness, mixed with a kind of spasm, the 
legs of the patient are either constantly kept stretched 
out straight, in which case considerable force is required 
to bend the knees, or they are by the action of the 
stronger muscles drawn across each other, in such man- 
ner as to require as much to separate them : when the 
leg is in a straight position, the extensor muscles act so 
powerfully as to require a considerable degree of force 
to bend the joints of the knees ; and when they have 
been bent, the legs are immediately and strongly drawn 
up, with the heels toward the buttocks : by the rigidity 
of the ancle joints joined to the spasmodic action of the 
gastrocnemii muscles, the patient's toes are poiuted down- 
ward in such manner as to render it impossible for him 
to put his foot flat to the ground : which makes one of 
the decisive characteristics of the distemper. 

"These are strong marks of the distinction which 
ought to be made between the two diseases : and fully 
sufficient to shew the impropriety of confounding them 
with each other. 



276 ELEMENTS OF SURGERY. 

" The majority of those who labour under this disease 
are infants, or young children : adults are by no means 
exempt from it, but I have never seen it at an age beyond 
forty. 

" When it attacks a child who is old enough to have 
walked properly, its auk ward and imperfect manner of 
using its legs, is the circumstance which first excites at- 
tention, and the incapacity of using them at all, which 
very soon follows, fixes that attention, and alarms the 
friends. 

" The account most frequently given is, that for some 
time previous to the incapacity, the child had been ob- 
served to be languid, listless, and very soon tired ; that 
he was unwilling to move much, or briskly ; that he had 
been observed frequently to trip and stumble, although 
no impediment lay in his way ; that when he moved 
hastily or unguardedly, his legs would cross each other 
involuntarily, by which he was often and suddenly 
thrown down ; that if he endeavoured to stand still, and 
upright, unsupported by another person, his knees would 
totter and bend under him : that he could not with any 
degree of precision or certainty, steadily direct either 
of his feet to any particular point, but that in attempting 
so to do, they would be suddenly, and involuntarily, 
brought across each other ; that soon after this, he com- 
plained of frequent pains and twitchings in his thighs, 
particularly when in bed, and of an uneasy sensation at 
the pit of his stomach ; that when he sat on a chair, or 
a stool, his legs were almost always found across each 
other, and drawn up under the seat ; and that in a little 
time after these particulars had been observed, he totally 
lost the power of walking. 

" These are the general circumstances which are 
found, at least in some degree, and that pretty uniform- 
ly in most infants and children, but there are others 
which are different in different subjects. 



ELEMENTS OF SURGERY. 277 

u If the incurvation be of the neck, and to a consider- 
able degree, by affecting several vertebrae, the child finds 
it inconvenient and painful to support its own head, and 
is always desirous of laying it on a table or pillow, or 
any thing to take off" the weight. If the affection be of 
the dorsal vertebrae, the general marks of a distempered 
habit, such as loss of appetite, hard dry cough, labo- 
rious respiration, quick pulse, and disposition to hectic, 
appear pretty early, and in such a manner as to demand 
attention : and as in this state of the case there is al- 
ways, from the connexion between the ribs, sternum, 
and spine, a great degree of crookedness of the trunk, 
these complaints are by every body set to the account 
of the deformity merely. In an adult, the attack and 
the progress of the disease are much the same, but there 
are sonic few circumstances which may be learned from 
a patient of such age, which either do not make an im- 
pression on a child, or do not happen to it. 

" An adult, in a case where no violence hath been 
committed, or received, will tell you, that his first inti- 
mation was a sense of weakness in his back bone, ac- 
companied with what he will call a heavy dull kind of 
pain, attended with such a lassitude as rendered a small 
degree of exercise fatiguing : that this was soon follow- 
ed by an uuusual sense of coldness in his thighs, not ac- 
countable for from the weather, and a palpable diminu- 
tion of their sensibility. That in a little time more, his 
limbs were frequently convulsed by involuntary tvvitch- 
ings, particularly troublesome in the night : that soon 
after this, lie not only became incapable of walking, but 
that his power either of retaining or discharging his urine 
and fasces was considerably impaired, and his penis be- 
came incapable of erection. 

"The adult also finds all the offices of his digestive, 
and respiratory organs much affected, and complains con- 
stantly of pain and tightness at his stomach. 



278 ELEMENTS OF SURGERY. 

" In infants, the curve is seldom noticed till it has got 
to such a size and state, as to demand attention from the 
deformity : previous to this, all the marks of distemper 
which appear in the child, pass for the effects of general 
weakness, and are treated as such ; differently by differ- 
ent people, and under different circumstances, but never 
with any permanent good effect ; some of the adventi- 
tious symptoms, if I may so call them, are, in some de- 
gree, relieved, but the principal remain in full force, or, 
what is much more frequent, go on increasing. 

" In an adult it passes for rheumatism, or gravel, or 
a strain, and the defect in the limbs is the first thing that 
occasions an inquiry into the state of the back bone. 

" When a curvature is perceived in an infant, it is 
always supposed to have received a hurt by a blow, or 
fall, and an adult has always recourse to some exertion 
in pulling, drawing, lifting, or carrying, by which the 
spine is thought to have been deranged, or injured ; but 
which supposition is seldom, if ever true, in either case. 

" The true cause of the disease, is a morbid state of 
the spine, and of some of the parts connected with it; 
which distempered state of parts will, upon careful in- 
quiry, be always found to have preceded the deformity 
gome length of time ; in infants this is the sole cause, 
and external violence has nothing to do with it. In the 
adult, I will not assert that external mischief is always 
and totally out of the question, but I will venture to af- 
firm what is equal, as far as regards the true nature of 
the case, which is, that although accident and violence 
may in some few instances be allowed to have contri- 
buted to its more immediate appearance, yet the part in 
which it shews itself, must have been previously in a 
morbid state, and thereby predisposed for the production 
of it. I do not by this mean to say, that a violent ex- 
ertion cannot injure the spine, nor produce a paralytic 
complaint, that would be to say more than I know ; but 



ELEMENTS OF SURGERY. 279 

I will venture to assert, that no degree of violence what- 
ever is capable of producing such an appearance as I 
am now speaking of, unless the bodies of the vertebrae 
were by previous distemper disposed to give way ; and 
that no supposable dislocation, caused by mere violence 
done to the bones of the back, which bones were before 
the receipt of the injury in a sound state, can possibly 
be attended with the peculiar symptoms of a curved 
spine. In which distinction, according to my judgment, 
consists the very essence of the disease. Violence may 
easily be supposed to bring the two vertebrae nearer to 
each other than they ought to be, and by crushing an 
intermediate one to produce a curvature ; but then the 
body of the vertebrae so crushed, must have been in a 
distempered state previous to such violence : great vio- 
lence may also suddenly and immediately displace a per- 
fectly sound vertebra: from its proper and natural situa- 
tion, with regard to those annexed to it ; but the neces- 
sary consequences of these two kinds of injury must be 
so very different, that they never can be confounded to- 
gether, or mistaken for each other, even by the most in- 
attentive observer. 

" The true curvature is invariably uniform in being 
from within outwards ; but it varies in situation, in extent, 
and in degree ; it affects the neck, the back, or the loins ; 
it comprehends one vertebra only, or two, or more ; and 
as few or more are affected, or, as these are more or less 
morbid, and consequently give way more or less, the 
curve must be different ; but whatever variety these cir- 
cumstances may admit, the lower limbs alone,* in gene- 

" * Since I began to put these patera together, I have seen two cases, in one 
of which the arms only were affected, in the other both legs and arms. 

" Mr. E. Ford, of Golden Square, has favoured me with the examination and 
case of a lad, who lost the use of ho h legs, and bo h arms, from a curvature 
which Mr. Ford cured by means of ihe caustics. Mr Park, of Liverpool, has 
also obliged me with an account oi't ft <der his care, both with 

useless aims and legs, and both cured by the barue means." 



280 ELEMENTS OF SURGERY. 

ral, feel the effect. Some are very soon after the curva- 
ture, rendered totally and absolutely incapable, not only 
of walking, but of using their legs in any manner; others 
can make shift to move about with the help of crutches, 
or by grasping their thighs just above the knees with 
both hand* ; some can sit in an armed chair without much 
trouble or fatigue, others cannot sit ftp with any help ; 
some retain such a degree of power of using their legs, 
as to be able to shift their posture when in bed ; others 
have no such power, and are obliged to be moved upon 
all occasions. 

" Weak and delicate children are the most frequent 
subjects of this distemper ; and when in these, it seizes 
on the dorsal vertebrae, great deformity of the trunk, 
both before and behind, is the almost inevitable and. ne- 
cessary consequence ; this will be different in different 
persons ; but let the difference in this be what it may, it 
is an adjunct circumstance ; and upon due inquiry it will 
always be found that the curvature from w ithin outward, 
preceded the other deformity, and was, at one time, the 
only one to be seen. 

" Before the alteration of figure in the back bone has 
been discovered, all the attention is paid to the limbs, in 
which the whole disorder is supposed to reside ; and all 
the applications for relief are made to them : frictions, 
liniments, embrocations, blisters, &c. to which is gene- 
rally added cold-bathing and electricity ; when the cur- 
vature has been noticed, recourse is immediately had to 
back-boards, collars, steel bodice, swings, screw-chairs, 
and other pieces of machinery, but all to no purpose ; 
the patient becomes daily more and more helpless and 
unhealthy, languishes for more or less time, and at last 
dies either in an emaciated state from a hectic, or by a 
drain from an abscess formed within the body. 

« That this is the case frequent and melancholy expe- 



ELEMENTS OF SURGERY, 281 

vience evinces, but why it is so, is perhaps not generally 
so well understood, or attended to as it ought to be. 

" The primary and sole cause of all the mischief, is a 
distempered state of the parts composing or in imme- 
diate connexion with the spine, tending to, and most 
frequently ending in a caries of the body, or bodies, of 
one or more of the vertebrae : from this proceed all the 
ills whether general, or local, apparent, or concealed : 
this causes the ill health of the patient, and, in time, the 
curvature. The helpless state of the limbs, is only one 
consequence of several proceeding from the same cause; 
but though this effect is a very frequent one, and always 
affects the limbs in nearly the same manner ; yet the dis- 
ease not having its origin in them, no application made 
to them only can ever be of any possible use. 

" The same failure of success attends the use of the 
different pieces of machinery, and for reasons which are 
equally obvious. 

" Tney are all, from the most simple to the most com- 
plex, but particularly the swing and the screw, calcu- 
lated to obviate and remove what docs not exist. They 
are founded upon the supposition of an actual disloca- 
tion, which never is the case, and therefore they always 
have been and ever must he unsuccessful. 

" To understand this in the clearest and most con- 
vincing manner, we need only reflect on the nature of 
the disease, its seat, and the state in which the parts 
concerned must necessarily be. 

" The bones arc either already carious, or tending to 
become so; the parts connected with them are diseased, 
and not unfrequently ulcerated : there is no displacement 
of the vertebrae with regard to each other, and the spine 
"bends forward only because the rotten bone, or bones in- 
tervening between the sound ones give way, being unable 
in such state to bear the weight of the parts above. The 
most superficial reflection on this must point out to every 
Vol. II. o 



282 ELEMENTS OF SURGERY. 

one, why attempts of this kind can do no good, and a lit- 
tle more attention to the subject will show why they may 
be productive of real, and great mischief. The bones 
are supposed to be sound, but displaced; these machines 
are designed to bring them back to their former situation, 
and thereby to restore to the spine its proper rectitude ; 
if therefore they fratfe any power, that power must be 
exercised on the parts in connexion With the curve ; 
which parts, when the disease is at all advanced, are in- 
capable of bearing such a degree of violence without 
being much hurt thereby : this, if it were merely theo- 
retical, being a conclusion drawn from the obvious and 
demonstrable state of the distempered parts, could not 
be deemed unreasonable ; but, unfortunately for the af- 
flicted, it is confirmed by practice. They who have had 
patience and fortitude to' bear the use of them to such a 
degree as to affect the parts concerned, have always 
found increase of pain and fever, and an exasperation of 
all their bad symptoms, and I have known more than 
one instance in which the attempt has proved fatal. 

{i The use of some or other of these pieces of machinery 
is so general, and the vulgar prejudice in their favour 
so great, that notwithstanding I have been long con- 
vinced of their perfect inutility, yet if I had no other ob- 
jection to them, 1 would not attempt to rot) the afflicted 
of what they seem to derive such comfortable expecta- 
tion from : but as I am satisfied of their mischievous ef- 
fects, not only in the case of the present subject, but in 
many others ; I cannot help bearing my testimony against 
the indiscriminate and very improper use which is daily 
made of them. 

" They are used with design to prevent growing chil- 
dren from becoming crooked or misshapen, and this 
they are supposed to do by supporting the back-bone, 
and by forcing the shoulders unnaturally backward ; the 
former they cannot do. and in all cases where the spine 



ELEMENTS OF SURGERY. 283 

is weak, and thereby inclined to deviate from a right 
figure, the latter action of these instruments must con- 
tribute to, rather than prevent such deviation ; as will 
appear to whoever will with any attention examine the 
matter : if, instead of adding to the embarrassments of 
children's dress by such iron restraints, parents would 
throw off all of every kind, and thereby give nature an 
opportunity of exerting her own powers ; and if in all 
cases of manifest debility recourse was had to friction, 
bark, and cold bathing, with a due attention to air, diet, 
exercise, and rest, the children of the opulent would, 
perhaps, stand a chance of being as stout, as straight, 
and as well shapen as those of the laborious poor. 

" When a child appears to be what the common people 
call naturally weakly, whatever complaints it may have 
are supposed to be caused by its weak state, and it is 
generally believed that time and common care will re- 
move them ; but when a curvature has made its appear- 
ance, all these marks of ill health, such as laborious res- 
piration, hard cough, quick pulse, hectical heat and 
flushing, pain and tightness of the stomach, &c. are more 
attentively regarded, and set to the account of the de- 
formity consequent to the curve, more especially if the 
curvature be of the dorsal vertebra?, in which case the 
deformity is always greatest : but whoever will carefully 
attend to all the circumstances of this disorder, will be 
convinced, that most, if not all the complaints of chil- 
dren, labouring under this infirmity, precede the curva- 
ture, and that a morbid state of the spine, and of the 
parts connected with it, is the original and primary cause 

of both. 

" I have in the former edition informed the reader, that 
my particular attention to this disease was first excited 
by an instance of its being cured by a seemingly acci- 
dental abscess ; that this first gave me reason to suspect, 
that, we had mistaken an effect for a cause, and, that 



284 ELEMENTS OF SURGERY. 

upon mature deliberation upon the matter, I was stilt- 
more inclined to think so. for the following reasons. 

1. "That I did not remember ever to have seen this 
useless state of the limbs from a mere mal-formation of 
the spine, however crooked such malformation might 
have made it. 

2. " That none of those deviations from right shape, 
which growing girls are so liable to, however great the 
deformity might be, was ever attended with this effect 

3. " That the kind of deformity, which was attended 
with this affection, of the limbs, although it was different 
as to its degree, and its extent in different people, yet it 
was uniform in one circumstauce, which was, that the 
curvature always was from within outwards. 

4. " That since I had been particularly attentive to 
the disorder, I thought that 1 had observed, that neither 
the extent, nor degree of the curve, had in general pro- 
duced any material difference in the symptoms, but that 
the smallest was when perfectly formed, attended with 
the same consequences as the largest. 

5. f ( That although it had sometimes happened, that a 
blow, or a strain, had preceded the appearance of the 
curve, yet it much more frequently happened, that no 
such cause was assignable. 

6. " That I had observed exactly the same symptoms 
iu infants, and in young children, who had neither exert- 
ed themselves, nor were supposed to have received any 
injury from others ; and that the case was still the same 
in those adults, who had no such cau-e to look to. 

7. " That although it might be expected, that a dislo- 
cation of any of the vertebras, would be attended with 
symptoms of the paralytic kind, yet they would be very 
unlike to those which affected the limbs in the present 
case.*" 

"The suspicions which those circumstances had exci- 
ted in my mind, were confirmed by what I had a few op- 



ELEMENTS OF SURGERY. 285 

portunities of observing, in the dead bodies of some who 
had died afflicted with this disorder, and altogether sa- 
tisfied me, that there must be something predisposing iu 
the parts concerned ; and that when we attribute the use- 
less state of the limbs merely to the curvature, we mis- 
take, as I have just said, an effect for a cause. 

" At the same time I gave an account of a conversation, 
which passed between me and the late Dr. Cameron, of 
Worcester, who told me, that having remarked in Hip- 
pocrates, an account of a paralysis of the lower limbs, 
cured by an abscess in the back, he had, in a case of use- 
less limbs attended with a curvature of the spine, en- 
deavoured to imitate this act of nature by exciting a pu- 
rulent discharge, and that it had proved very beneficial; 
which was confirmed to me by Mr. Jefi'rys, of Worcester, 
who had made the same experiment with the same 
success. 

"From the time of my receiving this first information to 
the present, I have sought every opportunity of making 
the experiment ; St. Bartholomew's hospital has seldom 
beett without cases of this kind, and it is with infinite 
pleasure and satisfaction, that I find myself enabled to 
say, that in all Cases where the complaint has been so 
circumstanced as to admit of even probable expectation, 
the attempt has been successful. 
" If the cure of this most dreadful distemper had depend- 
ed upon an application to the constitution in general, it 
might have required a variety of medicines, the adminis- 
tration of which must have demanded judgment in adapt- 
ing them to particular persons and constitutions; and it 
must also, in the nature of things, have happened that 
many individuals could not have been benefited at all. 
But fortunately for the afflicted, the means of relief are 
simple, uniform, aud safely applicable to every indivi- 
dual, under almost every possible circumstance, not at- 
tended by the smallest decree of hazard, and capable of 



286 ELEMENTS OF SURGERY. 

being executed by any body who has the least portion of 
chirurgic knowledge : it consists merely in procuring a 
large discharge of matter, from underneath the mem- 
brana adiposa on each side of the distempered bones 
forming the curvature, and in maintaining such discharge 
until the patient shall have recovered his health and 
limbs. They who are little conversant with matters of 
this sort, will suppose the means very inadequate to the 
proposed end ; but they who have been experimentally 
acquainted with the very wonderful effects of purulent 
drains, made from the immediate neighbourhood of dis- 
eases, will not be so much surprised at this particular 
one ; and will immediately see how such kind of dis- 
charge, made, and continued from the distempered part, 
checks the further progress of the caries, gives nature an 
opportunity of exerting her own powers, of throwing off 
the diseased parts, and of producing by incarnation an 
union of the bones (now rendered sound) and thereby 
establishing a cure. 

" However, be all this as it may, the fact is undoubted, 
aud the number of witnesses, as well as patients produci- 
ble in confirmation of it is so considerable, that it is need- 
less to say any thing more on that head. 

" It is a matter of very little importance towards the 
cure, by what means the discharge be procured, provided 
it be large, that it come from a sufficient depth, and, that 
it be continued for a sufficient length of time.* 

" I have tried the different means of setons, issues by 
incision, and issues by caustic, and have found the last 
in general preferable, being least painful, most cleanly, 
most easily manageable, aud capable of being longest 
continued. 

" The caustics should be applied on each side of the 



* " When I say this, I mean to signify 1 hat it is absolutely without limitation, 
and must depend on their beneficial effect." 



ELEMENTS OF SURGERY. 287 

curvature in such a manner as to leave the portion of 
skin covering the spinal processes of the protruding 
bones, entire and unhurt, and so large, that the sores 
upon the separation of the eschars, may easily hold each 
three or four peas in the case of the smallest curvature ; 
but in large curves, at least as many more. 

" These issues should not only be kept open, but the 
discharge from them should be maintained by means of 
orange peas, cantharides in fine powder, aerugo asris, or 
any such application as may best serve the intended 
purpose, which should be that of a large, and long con- 
tinued drain. 

" Whatever length of time it may take to obtain a com- 
plete cure, by restoring the health as well as the limbs, 
the issues must be continued at least as long; and in my 
opinion, a considerable time longer, especially in the 
persons of infants and growing children ; the necessity 
of which will appear more strongly, when it shall be 
considered that infants and young children of strumous 
habits, are the subjects who are most liable to this dis- 
temper, and that in all the time previous to menstruation 
in one sex, and puberty in the other, they are in general 
more served by artificial drains than any other persons 
whatever. 

" This, and this only, does or can alleviate the misery 
attending this distemper, and in proper time effect a 
cure. 

" By means of these discharges, the eroding caries is 
first checked, and then stopped ; in consequence of which 
an incarnation takes place, and the cartilages between 
the bodies of the vertebras having been previously de- 
stroyed, the bones become united with each other and 
form a kind of anchylosis. 

" The time necessary for the accomplishment of this, 
must in the nature of things, be considerable in all ca- 



288 ELEMENTS OF SURGERY. 

ses, but very different according to different circum- 
stances. 

" No degree of benefit or relief, nor any the smallest 
tendency towards a cure is to be expected, until the ca- 
ries be stopped, and the rotten bones have begun to in* 
earn ; the larger the quantity of bones concerned, and 
the greater degree of waste and havock committed by 
the caries, the greater must be the length of time re- 
quired for the correction of it, and for restoring to a sound 
state so large a quantity of distempered parts, — and 
vice versa.* 

" In the progress towards a cure, the same gradation or 
succession of circumstances may be observed, as was 
found to attend the formation of the disease, with this 
difference, that they which attend the latter, are much 
more rapid than those which accompany the former. 

" After the discharge has been made some time, very 
uncertain what, the patient is found to be better in all 
general respects, and if of age to distinguish, will ac- 
knowledge that he feels himself to be in better health ; 
he begins to recover his appetite, gets refreshing sleep, 
and has a more quiet and less hectical kind of pulse, 
but the relief which lie feels above all others, is from 
having got rid of that distressing sensation of tightness 
about the stomach ; in a little time more a degree of 
warmth, and a sensibility is felt in the thighs, which 
they had been strangers to for some time ; and generally 
much about the same time, the power of retaining and 
discharging the urine and fasces begins to be in some de- 
gree exerted. 

" The first return of the power of motion in the limbs 
is rather disagreeable, the motions being involuntary and 

* " Nothing can be more uncertain than the time required for the cure of 
this distemper. I have seen it perfected in two or three months, and I have 
known it require two years ; two thirds of which time passed before there was 
any visible amendment." 



ELEMENTS OF SURGERY. 



289 



of the spasmodic kind, principally in the night ; and ge- 
nerally attended with a sense of pain in all the muscles 
concerned. 

" At this point of amendment, if it may be so called, 
it is no uncommon thing, especially in bad cases, for the 
patient to stand some time without making any farther 
progress ; this in adults occasions impatience, and in 
parents despair; but in the milder kind of case, the 
power of voluntary motion generally soon follows the in- 
voluntary. 

" The knees and ancles by degrees lose their stiffness, 
and the relaxation of the latter enables the patient to set 
his feet flat upon the ground, the certain mark that the 
power of walking will soon follow ; but these joints hav- 
ing lost their rigidity, become exceedingly weak, and 
are not for some time capable of serving the purpose of 
progression. 

" The first voluntary motions are weak, not constantly 
performable, nor even every day, and liable to great va- 
riation, from a number of accidental circumstances, both 
external and internal. 

" The first attempts to walk are feeble, irregular, and 
unsteady, and bear every mark of nervous, and muscular 
debility ; the patient stands in need of much help, and 
his steps, with the best support, will be, as I have just 
said, irregular and unsteady ; but when they have ar- 
rived at this, I have never seen an instance in which 
they did not soon attain the full power of walking. 

" When the patient can just walk, either with crutches, 
or between two supporters, he generally finds much trou- 
ble and inconvenience, in not being able to resist, or to 
regulate, the more powerful action of the stronger mus- 
cles of the thigh over the weaker, by which his legs are 
frequently brought involuntarily across each other, and 
lie is suddenly thrown down. 
Vol. II. P P 



290 ELEMENTS OF SURGERY. 

" Adults find assistance in crutches, by laying hold of 
chairs, tables, &c. but the best and safest assistance for 
a child, is what is called a go-cart, of such height as to 
reach under the arms, and so made as to enclose the 
whole body: this takes all inconvenient weight off from 
the legs, and at the same time enables the child to move 
them as much as it may please. 

" Time and patience are very requisite ; but they do 
in this case, as in many others, accomplish our wishes at 
last. 

" The deformity remaining after recovery is subject to 
great uncertainty, and considerable variety, as it depends 
on the degree of caries, and the number of bones affect- 
ed : in general, it may be said, that where one vertebrae 
only is affected, and the patient young, the curve will in 
length of time almost totally disappear ; but where two 
or three are affected, this cannot be expected ; the thing 
aimed at is the consolidation and union of the bones, 
which had been carious, and are now become sound : 
this is the sine qua non of the cure, and this must in such 
cases render the curvature, and consequently the defor- 
mity, permanent : the issues will restore the use of the 
limbs, but not the lost figure of the spine." (Pott.) 

Since the introduction of this method of treatment into 
general use many cures have been effected of this for- 
merly incurable disease, and the practice of Mr. Pott 
has been approved and adopted by all modern surgeons. 
In some instances advantage is derived from machinery 
so constructed as to support the head, but this is not 
often required. 

The curvature of the spine resulting from rickets is 
generally distinguishable from that in which the vertebra 
are carious. In rickets,' the curvature is gradual and 
extends throughout the whole spine; it is also very irre- 



ELEMENTS OF SURGERY. 291 

gular, and the spine is bent in several different direc- 
tions — in cases of caries a few of the vertebras only are 
affected, and the curve is more abrupt and angular. In 
rickets too the other bones of the body are generally af- 
fected ;-the sternum projects ;-the ribs are depressed ;-the 
bones of the pelvis fall inwards ;-the clavicles are pro- 
minent ;-the os humeri bulges outwards ;-the thighs are 
curved forwards and outwards ;-the knees are bent in- 
wards ;-tbe tibia is unusually convex and prominent ;-and 
the feet turn outwards. In short the whole skeleton in 
rickety subjects is deformed, and the whole appearance 
of the patient is feeble and sickly ; whereas the disease 
of the spine which has been described, is purely local, 
and appears to be unattended with any primary consti- 
tutional affection. 

Attempts have been made to cure the disease of the 
spine by simply confining the patient to bed. Of the suc- 
cess of this treatment I have no information, but it should 
certainly not supercede the employment of issues, from 
which so much benefit has been found to result. 



292 ELEMENTS OF SURGERY, 

CHAPTER XXXIII. 

Of Paronychia or WJiitlow. 

Paronychia, Panaris, or Whitlow is a very painful 
and distressing inflammation seated at the end of a finger 
or thumb generally terminating in suppuration. 

It is usually divided into four species, which differ 
merely in the degree and situation of the inflammation. 

The first species is the least severe. It is seated near 
the root or side of the nail, and when it suppurates, mat- 
ter is formed immediately under the cuticle, and the in- 
flammation appears to extend no deeper than the true 
skin. When, however, in this case the matter forms 
under the nail, as it sometimes does, great pain results 
from its confinement. 

In the second species of whitlow the inflammation oc- 
curs under the true skin, and commonly near the extre- 
mity of the finger. The pain is very great, probably be- 
cause the skin of the finger does not admit of ready dis- 
tention in the inflamed vessels, and when suppuration 
takes place the matter is confined, and the abscess does 
not soon open. 

The third species is that in which the inflammation 
is still more deeply seated, and affects the parts within 
the theca covering the flexor tendons. In this case the 
inflammation and suppuration frequently extend along 
the tendons to the wrist, and even to the elbow. 

In the fourth species the periosteum and sometimes 
the bone inflames. In this case the inflammation and sup- 
puration do not generally extend so far as in the third 
species. 



ELEMENTS OF SURGERY. 298 

In the two last cases the pain is very excruciating, 
and there is no great tumefaction evident. 

Besides these four species of whitlow a fifth has heen 
noticed affecting the bone exclusively, attended with ex- 
treme pain, continuing for weeks and months with inter- 
vals of ease, and occasional exacerbations. In one such 
case the finger is stated by Richter to have been re- 
moved, and the bone on examination was found entirely 
destroyed and changed into a fatty substance. 

The causes of whitlow are not always known ; vicis- 
situdes of temperature frequently occasion it. I have 
seen more cases of whitlow aiming washerwomen than in 
any other class of persons. Punctured wounds have 
sometimes produced paronychia. 

The most distressing cases of the disease are those in 
which the inflammation and suppuration proceed aiong 
the tendons, under the aponeurosis pal maris, and under 
the annular ligament of the wrist to the fore arm. Some- 
times gangrene results, and limbs have been amputated 
in consequence of whitlow, and death has in some cases 
followed this apparently trivial complaint. 

TREATMENT. 

The manner of treating paronychia varies somewhat 
according to the situation of the intlammation. In the 
first species it is necessary to evacuate the matter as soon 
as it forms, and in general it readily heals ; the best ap- 
plication is the common epulotic cerate. If matter form 
under the nail it can be plainly seen, and must be eva- 
cuated, by scraping the nail very thin with glass or a 
sharp knife and then dividing it with a bistoury. 

When the inflammation is deeper seated and great 
pain results, the patient should be bled aud purged. 
The application of leeches is also very effectual in aba- 
ting the inflammation. A blister should be applied over 



294 ELEMENTS OP SURGERY. 

the part. In some cases advantage has been obtained 
from rubefacients, as hot water, &c. but the blister 
is to be preferred. As soon as matter forms, how- 
ever, it should be evacuated by a free incision, and 
whenever paronychia is attended with severe pain, and 
the skin is not very red and sensible, we may infer that 
the inflammation is situated in the tendon or periosteum, 
and therefore an early and free incision in the direction 
of the tendon should be made down to the bone, which 
generally procures very speedy relief, evacuates matter 
if it be already formed, removes the tension of the parti 
if suppuration have not taken place, and substitutes a 
simple incision which will readily heal, for a most obsti- 
Bate, painful, and dangerous malady. 

When matter travels along in the course of the ten- 
don .■>, free incisions should be made for its evacuation, 
and if carious bone be found it should be extracted as 
soon as it becomes sufficiently loose. 

It often happens that the tendons exfoliate or slough, 
a tedious process which prolongs the disease and pre- 
vents the soft parts from healing. In these cases if prac- 
ticable, the diseased tendon should be cut off, and with 
it a small portion of the sound tendon, for unless the in- 
cision be made in a sound part the cure will not be ex- 
pedited, since the absorbents will have still their work 
to perform. 

Fungus sometimes protrudes through the external 
opening, which should always in such cases be enlarged, 
to give free vent to confined pus, and to remove all stric- 
ture from the inflamed parts. 



ELEMENTS OF SURGERY. 295 



CHAPTER XXXIV. 



Of Amputation of the Limbs. 

What the surgeon cannot cure he removes by his 
knife. If his art were perfect he would never amputate, 
but in the present state of medical science even this ter- 
rible operation is occasionally demanded. The modern 
improvements of surgery have lessened the number of 
cases which call for amputation, and have greatly miti- 
gated its horrors, but it still leaves the patient a muti- 
lated victim, and it is an operation " terrible to bear and 
dreadful to behold." 

It is important for a surgeon to be well convinced of 
the propriety of amputation before he resolves upon it. 
He should never consider it as one of his remedies, but 
as an apology for their inefficacy, and notwithstanding 
this he should be ready to amputate when necessity de- 
mands it, and prompt to decide when that necessity 
exists. 

It is customary in systematic works to collect together 
a number of aphorisms to regulate the practitioner on the 
present occasion. I shall comply with the custom to a 
certain extent, premising that exceptions may be as nu- 
merous as the rules, and in many cases the best practice 
will consist in violating the best general directions, and 
a familiar acquaintance with every principle of surgery 
will be necessary in forming a judgment upon the end- 
less variety of cases which may involve the question of 
the propriety of amputation. 

I. Compound fractures have been supposed to ren- 
der amputation necessary. We have already remarked 



296 ELEMENTS OF SURGERY. 

(page 110, vol. 1.) that a broken bone affords no just 
reason for the operation. The concomitant injury and the 
circumstances under which the attempt to cure the patient 
will be made are the principal things to be taken into 
consideration. On the field of battle, or in the cock-pit 
amputation is warrantable and proper, in cases which 
would not justify it in the comfortable residence of an 
affluent citizen. To anticipate the particulars of each 
case is impossible. 

II. Compound dislocations are of a very serious 
nature, and are often complicated with other important 
injury to a limb. In hot weather such accidents not 
unusually terminate in tetanus — sometimes in gangrene — 
often in violent inflammatory fever — or in a profuse 
discharge of pus, and consequently great exhaustion and 
hectic fever. In these cases amputation is therefore a 
subject of serious deliberation. The dangers should be 
stated fairly and freely to the patient and his friends, and 
the surgeon should rather direct and inform, than con- 
trol their decision, always bearing in mind that many 
desperate cases get well under judicious and attentive 
treatment. 

III. Extensive wounds. Many wounds occur which 
render amputation indispensable. A limb is shot off by 
a cannon ball — It is lacerated by a splinter and all its 
important blood-vessels torn open. Under such circum- 
stances immediate amputation substitutes a simple inci- 
sion for a ragged, lacerated, dangerous wound. In these 
cases no time should be lost. Ranby or Wiseman relates 
a case in which a sailor in an engagement had one of his 
arms shattered, went to the cock-pit, and after it was am- 
putated sprung upon deck, nothing daunted, and assisted 
with the other to traverse a gun. The operation is bet- 
ter borne immediately after the accident than at any other 
time. 

IV. Mortification. When a limb mortifies from 



ELEMENTS OF SURGERY. 297 

want of blood, or from excessive inflammation, the ab- 
sorbents if left to themselves will perform the amputation 
but in a slow and slovenly manner, and an irregular 
stump will be left. The surgeon should never ampu- 
tate whilst mortification is progressive, but if necessary 
afterwards he may perform the operation for the pur- 
pose of expediting the cure. 

V. Diseased joints ; — cancerous and other in- 
curable ulcers, sometimes render amputation neces- 
sary. The great exhaustion of the patient, and his 
apparently approaching death, arc the only good reasons 
for amputating in such cases, since many diseases 
supposed incurable get well, and yet there are no in- 
stances where the benefit arising from amputation is so 
great and so immediate, as in cases such as we are now 
contemplating. I have known a pulse too frequent to be 
counted, become nearly natural in a few hours after the 
amputation of a scrofulous knee — the hectic was imme- 
diately relieved — the night sweats subsided — the strength 
rapidly returned, and in a few days, from the brink of 
the grave the patient was snatched to a place of safety, 
and speedily restored to health. 

VI. Certain tumours rapidly increasing, or tending 
to end in incurable ulcers, as, the fungus nematodes — 
certain exostoses, or bony excrescences — caries of the 
bones of a joint and limb. These and other incurable 
affections of a like nature, warrant and demand the am- 
putation of a limb. 

Hemorrhage may generally be stopped without am- 
putation, and aneurisms no longer afford a pretext for 
the operation, though many limbs have been lost in con- 
sequence of a deficiency of knowledge as to the proper 
treatment of these cases. The tying-up of the artery 
supplying a limb, should be preferred to amputation. 
Vol. IT. q q 



298 ELEMENTS OF SURGERY. 

Mr. Boyer in his clinical lectures at the hospital La 
Charite, recommended amputation of the leg in cases of 
dislocated astragalus, even when unattended with a 
wound, but for this practice I think there is no excuse. 

Compound luxations do not afford a sufficient reason 
for amputation, and in the opinion of most surgeons, un- 
less they be attended with very extensive injury to sur- 
rounding parts, the operation ought not to be done. In a 
simple luxation therefore the practice of Mr. Boyer 
should never be imitated. 

Mr. Larrey recommends amputation as a cure for te- 
tanus, in cases where this disease results from gun shot 
wounds. In some cases I have known this practice 
tried, but always without success. 

For a number of very interesting observations on the 
present subject, the reader is referred to a masterly per- 
formance of Mr. Pott, entitled " Remarks on the neces- 
sity and propriety of the operation of amputation in cer- 
tain cases and under certain circumstances. " 



ELEMENTS OF SURGERY. 299 



CHAPTER XXXV. 



Amputation of the Thigh. 

When the thigh is amputated in consequence of a dis- 
eased knee, the limb should be removed as low down as 
possible without cutting in diseased parts. Previously 
to this, and every painful operation, a dose of laudanum 
should be administered. 

The instruments necessary, are, a tourniquet — a com- 
press bandage — a large amputating knife — a scalpel — 
a retractor — a saw — bone nippers — sponges and warm 
water — a tenaculum — needles and ligatures — adhesive 
plasters — dry lint — lint spread with cerate — a pledgit of 
tow — and a muslin roller. 

It is best, in order to avoid embarrassment, to pro- 
vide two knives and two tourniquets, as accidents have 
sometimes rendered one of these instruments useless. 
•-r The patient should be seated on a table covered with 
a folded blanket (a dining table with the leaves down is 
very convenient) he should be supported by pillows, or 
by an assistant who takes him in his arms. The end of 
a roller folded to the thickness of a compress bandage 
is to be applied over the femoral artery at the upper and 
inner part of the thigh, and is to be kept in that situa- 
tion by one turn of the roller, over which the tourniquet 
is applied and buckled. The chief precautions in the 
application of the tourniquet are, to observe that the 
buckle is three or four inches distant from the screw, 
and that the two plates of the instrument are iu contact. 
The reason of these directions will appear obvious to any 



300 ELEMENTS OF 3URGEBY. 

person who examines the operation of the instrument ; 
I have known the strap hroken in consequence of the 
buckle coming in contact with the lower plate whilst 
the surgeon was screwing forcibly, and it has hap- 
pened that, the whole effect of the tourniquet has been 
lost in consequence of the remoteness of the plates 
at the time of its application. The tourniquet beipg 
buckled ou is to be screwed until the circulation is com- 
pletely stopped, which can be ascertained by examining 
the anterior tibial artery, where it passes over the top of 
the foot. When the thigh is amputated very high up, the 
artery may be compressed by the thumb of an assistant 
in the groin, and in case a tourniquet breaks, it is easy 
in this manner to arrest the hemorrhage till another is 
applied. 

The surgeon takes the position which he finds most 
convenient, on either side of the patient (and this he 
should do in all amputations since there is no important 
reason for preferring one side to the other, except his 
convenience at the time.) One assistant takes hold of 
the leg, the limb being grasped by another who draws 
the skin moderately up and thereby renders it tense. 
The surgeon with his large knife makes a straight inci- 
sion completely round the limb,extending in depth through 
the skin and fat, down to the fascia femoris. This skin 
and fat are then to be dissected loose from the fascia, and 
for this purpose the amputating knife is exchanged for a 
scalpel ; when a sufficiency of integument is thus separated 
to cover the end of the stump, it is to be reverted, and 
held bark by an assistant. The surgeon again takes the 
amputating knife, and divides the muscles down to the 
bone, close to the reverted integuments. In this stage of 
the operation he should guide the edge of the knife by 
his eye, and be particularly cautious not to cut through 
the skin turned up, a piece of awkwardness utterly in- 



ELEMENTS OF SUlKiEKY. 301 

excusable. The retractor, a piece of slit linen or leather, 
is now applied to defend the muscles from the saw, and 
the assistants holding the limb above and below very 
steadily, the surgeon proceeds to saw through the bone. 
The cautions I wish to offer on this stage of the opera- 
tion, are, not to scrape up with a knife the periosteum 
from the bone — a useless, painful, and tedious business, 
and one which will be apt to occasion exfoliation. 2. 
To use long strokes of the saw, which prevents the 
choaking of the teeth, and expedites the operation. 3. 
Never to use a saw in which the teeth are not set wide, so 
as to make a groove wider than the thickness of the blade 
of the saw. If this be not attended to the saw hitches 
in the bone, its motions are irregular, and the bone often 
breaks off before it is cut through. The limb being thus 
removed, the surgeon proceeds to tie the femoral artery 
with a strong ligature ; he will easily see it near the 
bone, and probably several other large vessels will be 
obvious each of which is to be drawn out by a tenacu- 
lum and tied in succession. The tourniquet is now to 
be loosened, and a jet of blood takes place from every 
considerable artery not yet secured ; these are all to be 
taken up, and the stump cleansed with warm water and 
a clean sponge. The tourniquet and compress are now 
to be taken off. 

The bleeding having ceased, it is proper to wait a few 
minutes, and give the patient a little wine to excite the 
circulation, as a fainty state often stops the bleeding for 
a time before the arteries are secured. 

If no blood flows the skin is to be drawn over the end 
of the stump, wiped dry, and carefully approximated, 
and it is of no importance whether this be done in a line 
from side to side, or from before backwards. The liga- 
tures are to be brought out at each angle of the wound, 
and a small 'piece of lint interposed between the edges 
of the skin, m order to prevent the union of the skin be- 



802 ELEMENTS OF SURGERY. 

fore the flap and muscles have united. A caution of 
much importance, as the neglect of it has occasioned in 
many cases an abscess to form from the confinement of 
blood and serum under the flap which have greatly re- 
tarded the cure. The occurrence of this accident is I 
believe a very principal reason why the French surgeons 
do not avail themselves of the adhesive inflammation in 
the present case. They believe it impossible for the 
skin and muscles to unite by the first intention, and they 
consequently cover the stump with lint. The fact is, 
much of the union will be accomplished by the first in- 
tention, if the plan I have suggested be adopted. Straps 
of adhesive plaster are now to be applied in order to se- 
cure the skin in its proper situation ; over this a pledgit 
of lint spread with simple cerate, and over this pledgit 
another of fine tow, which is to be secured by a roller. 
The malta cross — the elongates — the knitted cap — are 
all ussless envelopes ; the best of all is a roller properly 
applied. This roller is to be passed repeatedly round 
the lower part of the thigh, and after crossing the stump 
in opposite directions, is to be carried by circular turns 
up to the hip, and passed once or twice round the loins 
to prevent it from slipping down. The tourniquet is now 
loosely applied around the top of the thigh to be ready 
in case of bleeding, and the patient is laid on a mattress. 
The stump being placed on a pillow, a cradle is to be 
fixed over it as in cases of fracture to prevent the pres- 
sure of the bed clothes. 

The patient should be kept at rest — some pain and 
soreness of the thigh may be expected, but the stump 
should not be touched till the eighth day in cool weather, 
or the fourth or fifth day in summer, at which time it is 
to be dressed. 

In removing the dressings great caution must be used 
The bandages should be well soaked in warm water, 



ELEMENTS OP SURGERY. 303 

and poulticed for some hours, if necessary, to soften 
them. 

The dressings are to be reapplied as at first, and this 
should be repeated once in forty- eight hours, and after 
the third or fourth dressing every day. The liga- 
tures generally come away in a fortnight, and the stump 
in a successful case heals in three or four weeks. 

If there be any reason to suppose the femoral artery 
in a diseased state, and especially if it be found ossified, 
it will be proper to take it up with a needle, and the li- 
gature should include a portion of the surrounding sub 
stance. It is of no great consequence to avoid enclosing 
a nerve in the knot, for I am convinced that this is often 
done without occasioning spasms of the stump or any 
other inconvenience ; nevertheless I do not recommend 
it to be done if it can be conveniently avoided. 

When the patient begins to use a wooden leg, great 
care should betaken to prevent ulceration of the stump. 



304 ELEMENTS OF SURGERY. 



CHAPTER XXXVI. 



Amputation of the Leg. 

The method of amputating the leg which I shall re- 
commend, is one very easily performed, and equally suc- 
cessful with any other ; avoiding therefore, as usual, a 
history of successive improvements, I proceed to de- 
scribe it in the manner in which it has been for mauy 
years performed by Dr. Physick. 
. The instruments and previous preparations are the 
same as have been recommended for amputation of the 
thigh, with the addition of a catlin, or double edged 
knife, and a retractor with three instead of two tails. 

The tourniquet need not be placed so high upon the 
thigh, but it is better to affix the compress under it at the 
spot where the femoral artery is tied in cases of popli- 
teal aneurism, and not as has sometimes been advised, 
low down near the knee, because the ham strings take 
off much of the pressure from the artery and render it 
necessary to screw it much tighter. 

The circulation being commanded, an assistant holds 
the foot and leg steady, another secures the knee, and 
the surgeon standing if convenient* on the inside of the 
knee, makes an incision with the amputating knife about 
five inches below the putella, in front ; extending consi- 
derably lower down behind, so as to be more distant 
from the knee behind than before. This incision is to 
be carried regularly round the limb, and deep enough to 

* I use this word, because, the direction of the light, the number of attend- 
ants, the size of the apartment, and many circumstances, may interfere with 
♦his arrangement. 



ELEMENTS OF SURGERY. 305 

divide the skin and adipose matter down to the fascia co- 
vering the muscles. With a scalpel the integuments are 
to ]>e dissected loose and turned back, the surgeon ta- 
king care to reserve enough to cover the stump, and no 
more. A flap will in this manner be formed, consisting 
of the skin and cellular membrane, which should meet 
just behind the tibia, of course about one inch of skin 
should be reserved in front. When this flap is turned 
back, with the amputating knife, or catlin (which Mr. 
C. Bell prefers) the surgeon proceeds to divide the mus- 
cles down to the bones, and inserting the catlin between 
4he tibia and fibula, he divides the interosseous flesh and 
ligament. The retractor is next applied, one strip being 
interposed between the bones, and being drawn up by an 
assistant so as to protect the muscles, the surgeon saws 
through the bones in such a manner as to cut through 
the fibula by the time the tibia is about half divided : 
the object of this is to prevent the lesser bone from 
breaking into splinters, when the support of the greater 
is removed. Any spicule which may project from 
either bone, can be removed with the nippers, and af- 
terwards the arteries are to be taken up. , There are 
generally three which may readily be found : the anterior 
tibial between the bones, and a little anterior to the in- 
terosseous ligament ; the posterior tibial lying a little to 
the inside of the former vessel near the tibia ; and, the 
fibular artery, near to, and behind, the fibula. The 
tourniquet being loosened, other vessels will be observ- 
ed, and these must successively be taken up. 

The dressings are to be applied in the same manner 
as when the thigh is taken off, except, that in folding the 
skin over the tibia, care must be taken not to compress 
it by the plasters or dressings too firmly, as the sharp 
edge of the bone sometimes occasions ulceration. 

In many cases the disease for which a leg is removed, 
is situated on the foot, at the ankle, or so low in the leg 
Vol. II. R r 



306 ELEMENTS OF SURGEUY. 

that the surgeon may choose at what part to amputate. 
In these cases if the patient be wealthy, and not very de- 
sirous of walking much after his cure, we may cut the 
leg low down, within a few inches of the ankle, and a 
cork supplement can be adapted to the stump ; but in 
persons accustomed to labour, it will be best to operate 
near the knee, and have a wooden leg adapted to the 
flexed knee, so that the patient may bear his weight upon 
originally formed parts, which are not so liable to ulce- 
rate as the surface of a cicatrized stump. 

The operation last described is adapted to the re- 
moval of any part of the limb between the ankle and 
knee, and I believe possesses all the real advantages of 
the common flap operation. 

If the ligatures do not remain long enough to retard 
the cure, the stump, in a healthy patient, generally heals 
in three or four weeks. It is a great desideratum to be 
able to remove ligatures when they cease to be neces- 
sary. 



ELEMENTS OF SURGERY. 307 



CHAPTER XXXVII. 



Amputation of the Arm. 

The amputation of the arm above the elbow, resembles 
so much that of the thigh, that it is unnecessary to de- 
scribe it. 

The amputation below the elbow resembles very much 
that of the leg, except that instead of the oblique inci- 
sion through the integuments, a circular or straight inci- 
sion is made. 

After amputating the arm, it is unnecessary to prevent 
by interposing a piece of lint, the union of the wounded 
skin, because the cut surfaces are so small that union by 
the first intention often takes place throughout the stump, 
the whole of which heals as soon as the ligatures come 
away. I have amputated a fore-arm, and in ten days 
found the stump entirely healed. 

When the arm is taken oft' near the wrist, some incon- 
venience results from the irregular contraction of the 
muscles, in consequence of which the tendons protrude 
very unequally from the stump ; those which project are 
easily however removed with the scissors. One of the 
most common cases demanding the amputation of the 
fore arm, is the bursting of a fowling piece, the left hand 
being placed near the breech of the gun, receives the 
load, and becomes so much shattered that it is impossi- 
ble to save it. and immediate amputation becomes re 
quisite 



308 ELEMENTS OF SUliGERY. 

CHAPTER XXX VIII. 

Of amputation of the shoulder joint. 

This is a very serious operation, and may become ne- 
cessary from gun-shot wounds, from exostoses or bony 
tumours of rapid growth near the head of the humerus, 
from fungus nematodes and certain analogous cases. 

The operation of removing the arm at the shoulder 
joint, was first performed by the elder Morand and af- 
terwards by Le Dran, who describes very particularly 
the manner in which he operated. Various modes have 
since been adopted, which I shall not detail, but, hav- 
ing never had occasion to perform the operation on the 
living body, I shall describe the manner in which it 
is done by the most celebrated surgeons of the present 
day. 

The French surgeons amputate at the shoulder in the 
following manner. The patient is seated on a chair, 
his head leaning against the breast of an assistant ; 
the operator placed at the external side of the limb, 
makes a first transverse incision down to the bone, at 
the inferior and anterior part of the deltoid muscle ; a 
second incision is made longitudinally from the caracoid 
process to the internal angle of the firsthand a third pos- 
teriorly, from the level of the articulation to the external 
extremity of the transverse incision ; having thus cut the 
flap, he dissects it and turns it up, pressing the lower 
part of the arm against the trunk, to make the head of 
the humerus project, he then cuts the tendons of the 
teres minor, supra-spinatus, infra- spinatus, and biceps 
muscles ; this done he rotates the arm backwards, cuts 



ELEMENTS OF SURGERY. 309 

the ligaments of the articulation, luxates ihe arm back- 
wards, compresses the flesh, by which the arm is yet 
held to the trunk, and lastly stops the hemorrhage from 
the brachial artery, and finishes the formation of the 
flap ; the arm being separated from the trunk, he imme- 
diately proceeds to apply the ligatures, bring back the 
flap, and secure it by adhesive plaster, lint, compresses, 
&c. This operation will be less painful, and more quick- 
ly executed, if the external flap is formed by a single 
stroke, by using a double edged knife, with which the 
surgeon may divide the deltoid at its base, and passing 
from top to bottom along the bone, until it comes within 
four fingers breadth of the articulation where the flap 
terminates. This mode of operating has been practised 
with great dexterity by professor Dupuytren, and is par- 
ticularly described in the first volume of the Dictionaire 
des Sciences Medicales," published at Paris in 1802. 

The celebrated and venerable Mr. Cline of London, 
has contrived an operation, much more simple than this. 
My friend Dr. J. A. Smith of New-York who has seen 
Mr. Cline operate, thus describes to me his opera- 
tion. " The artery being previously secured by pres- 
sure on the first rib, an assistant takes hold of the arm, 
and pulls it from the body obliquely downwards, the sur- 
geon being provided with a narrow knife, takes up with 
his left hand as much of the deltoid muscle as he thinks 
will be sufficient to form a flap to cover the wound. The 
knife is then introduced in such a direction as to pass 
slant- wise between the acromion process and the head 
of the humerus ; around the head of that bone the in- 
strument makes a semicircular sweep within the glenoid 
cavity, dividing at one stroke all the muscles which 
connect the arms with the scapula and body. The whole 
operation is little more than a simple incision, and is per- 
formed with a facility perfectly astonishing to those who 
see it for the first time, and if the surgeon have formed 



310 ELEMENTS OF SURGERY. 

his flap of the proper size, it covers the wound with great 
accuracy." 

This operation, once considered among the most ter- 
rific in surgery, has become familiar among military sur- 
geons, and in consequence of its frequent performance of 
late years, has almost ceased to be an object of dread, 
and Mr. Guthrie declares " that this once formidable 
operation may be considered as safe, as simple, and as 
little hazardous as any other of importance performed on 
the human body." I shall subjoin some of his observa- 
tions respecting it. 

" This operation has until lately been considered of 
the utmost danger and importance, not only to the life 
of the person who is unfortunately the sufferer, but to the 
reputation of the surgeon who has the performance of it : 
many and various have therefore been the methods re- 
commended for conducting it, all impressing on the 
mind of the operator the great extent of danger, and 
tending to disturb the steadiness of his judgment. 
Anatomy, which has thrown so much light on operative 
surgery in general, has not failed in the last few years 
to dispel the cloud that obscured this part of military 
surgery ; and experience has proved it to be as simple, 
easy, and safe an operation, as any other of importance 
performed on the field of battle. The knowledge ac- 
quired from this source of its success, has given to mili- 
tary surgeons a confidence in performing it, that divests 
it of half its former terrors, and by removing from the 
mind of the patient the idea of his having suffered a 
hopeless operation, diminishes the subsequent danger, 
and most materially aids his recovery. The dread for- 
merly entertained of this operation was very great, even 
by men of the best abilities ; and under certain circum- 
stances in domestic surgery, it may still be tedious. It 
can never however again be considered formidable in 



ELEMENTS OF SURGERY. 311 

military surgery, except under bad management, and 
from extreme ignorance. 

The distinction between the necessity of the opera- 
tion, and the possibility of avoiding it, requires in many 
cases the exercise of the nicest judgment, and a due 
consideration of attending circumstances ; for there is 
no part of military surgery, in which an operation can 
be performed with more advantage at the instant ; or, 
delayed for a few days with a view of gaining informa- 
tion, with more prejudice ; inasmuch as the necessary 
incisions! are made in the first instance, in parts dis- 
posed to take on healthy actions, and in the best possi- 
ble state for undergoing surgical operations. The con- 
stitution of the patient being also at that moment gene- 
rally good, and able to sustain the demands upon it. 
under untoward circumstances ; or of supporting, with- 
out future injury, the restraint and control requisite for 
the successful accomplishment of the cure. 

The difference between cutting in sound and diseased 
parts is justly appreciated by every surgeon, both as to 
his personal convenience and ease in operating, as well 
as to the future healing of the wound ; and the advan- 
tage here is particularly great, as from the contiguity of 
the wound to the chest and the principal organs of life, 
it is advisable to avoid any excess of action ; and expe- 
rience has demonstrated that the evil to be apprehended 
from the equilibrium of the circulation being destroyed, 
is infinitely less than it would be at a subsequent period 
of three or four weeks, after high suppurative action has 
been going on. In the latter, the operation is delayed 
until the parts to be divided have been long carrying on 
an increased action, and may even be diseased. The 
health and strength of the patient have been so much 
reduced, that he may be unable to support the additional 
pain and shock of the operation, which increase with 
the delay, or of giving that assistance requisite for the 



312 ELEMENTS OF SURGERY. 

consolidation of the wound. Another and great con- 
sideration, is the ease and safety with which a person 
can be moved after the operation, compared with the 
danger and pain resulting from the disturbance of broken 
bones, the increase of inflammation, and other attendant 
evils under the same circumstances. It cannot be there- 
fore too strongly impressed on the mind, that the neces- 
sary examinations should take place ; and the operation 
be performed in those cases demanding it, as soon after 
the injury as possible, consistent with the state of the 
patient ; and the surgeon should not satisfy himself with 
the idea of being able to accomplish it as safely, or as 
successfully, wlven suppuration has been established, 
and when perhaps he may have better assistance at hand ; 
a kind of self deceit that is occasionally permitted, but 
which cannot be too much reprobated. 

The importance of the arm is so great, and even a 
limited use of it so valuable, that much should be hazard- 
ed to save it, when there is a tolerably fair prospect of 
success : the situation also and structure of the upper 
extremity, together with the command the surgeon has 
over it, and the less proportionate inconvenience resulting 
from a severe wound in that part to any other of equal 
value, renders its preservation after a serious injury, 
more practicable, and less dangerous than is frequently 
supposed. The operation should not therefore be per- 
formed, unless simple amputation by the flap operation 
cannot be successfully accomplished ; or, where the 
limb is evidently destroyed, or, the injury seriously 
affecting the articulation itself, while the general health 
of the patient, or the unfortunate circumstances of situ- 
ation, render the attempt at a farther perseverance in 
saving the limb improper. 

Injuries from musket-balls penetrating the capsular 
ligament, attended „with fracture and destruction of the 
head and adjacent parts of the humerus, and wounding 



ELEMENTS OF SURGERY. 313 

the axillary artery, require immediate operation.* A 
simple penetrating or incised wound of the joint, of 
small extent, does not rail for any operation, as the pa- 
tient, with due rare, will escape with a certain decree 
of loss of motion, and of debility in the joint ; nor is it 
proper in a wound from a musket-ball, where there is 
even some partial injury of the bone, as these cases fre- 
quently do well, and the patient preserves the use of 
the fore- arm. * 

Mr. Guthrie proceeds to state at great length, "acci- 
dents in the field," and " subsequent occurrences/'" 
which may demand the operation : for these the reader 
is referred to his work. — 

It is now time to correct another misapprehension 
that the fear of haemorrhage has introduced into this 
operation ; I allude to the idea prevalent amongst many 
surgeons, that it is to be performed in a different manner 
from any other of importance ; that instead of the calm, 
steady determination that distinguishes a surgeon of 
ability, who feels himself master of his suhject, he is to 
forget or lay aside, what on all other occasions is con- 
sidered most valuable, and endeavour to attain a pecu- 
liar precipitation and haste of manner, that is excluded 
from all other parts of surgery. There is still a prac- 
tical point usually overlooked, that in military surgery 
there is little or no arm left to use as a lever in facilita- 
ting the operation, and that the separation of the head 
of the bone depends upon the surgeon, and not upon the 
assistants. 

The patient should be placed on a seat lower than 
the surgeon ; (in the field a hospital pannier is the best) 
and so supported that he may not be able to slide off 
during the operation, the assistant in charge of the tour 

* General Scott of the United States army, happily recovered from S" 
wound and has a v< is useful 

Vol, II 8 i 



314 ELEMENTS OF SURGERY. 

niquet, or instrument described,* standing behind, and 
regulating the support in such manner that he may 
always be able to make steady compression when re- 
quired. The shattered arm or stump is then to be raised 
from the body, sufficiently to enable the hand of the . 
operator to examine the axilla, and ascertain that his 
assistant can compress the artery when he pleases ; for 
this simple motion of raising the arm to near a right 
angle with the body, to afford access to the axilla after 
the pressure is made, will frequently render some alter- 
ation of it necessary. The arm should be also raised, 
so as to point out more clearly the insertion of the pec- 
toralis major, and the posterior fold of the arm-pit ; and 
as being more convenient to the operator, who, placing 
his finger on the lower end of the acromion process in 
the centre of the shoulder, (the hair in the axilla having 
been previously removed) with the smaller amputating 
knife commences his incision immediately below it, and 
with a gentle curve carries it downwards and inwards 
through the integuments only, a little below the anterior 
fold of the arm-pit, and which the raising of the arm 
readily points out. The second incision outwards, is 
made after the same manner, but something lower down, 
and is continued underneath, so as to shew the long 
head of the triceps at the under edge of the deltoid, 
without dividing any of the muscular fibres ; by which 
means the skin has time and freedom to retract, which 
is a great object, being the part in general most wanted, 
and when retracted allows of subsequent extension. 
The third incision commencing at the same spot as the 
first, but following the margin of the retracted skin, di- 
vides the deltoid on that side to the bone, and exposes 
the insertion of the pectoralis major, which must be per- 
fectly cut through, to shew the short head of the biceps 

* The hanll'- of the common tourniquet covered with a linen bolster, is to 
be pressed by an assistant on the subclavian artery where it crosses the first rib 



ELEMENTS OF SURGERY. 315 

flexor cubiti, and the coraco brachialis, which are then 
readily known by their longitudinal fibres, and the 
freedom the arm or stump receives from losing its attach- 
ment to the fore part of the chest : these two muscles 
however are not to be touched, although the flap thus 
formed is to be separated, and raised so as to expose 
the head of the bone, nearly as far as the coracoid pro- 
cess of the scapula. The fourth incision outwards, in 
the same manner divides the deltoid muscle down to the 
bone, and extending to the long head of the triceps, 
which it is not necessary to touch, as it would be after* 
wards divided : this flap is to be well turned back, so 
as to shew the insertions of the teres minor and infra 
spinatus, coming across horizontally from the scapula, 
to be inserted into the great tuberosity of the humerus ; 
the posterior circumflex artery will be divided close to 
the bone, the anterior circumflex, and the continuation 
of the thoracica humeriana on the integuments of the 
arm, and some other small vessels may bleed, if the 
compression be not correctly applied ; they ought not 
however to be tied, but merely stopped with the finger, 
and particularly the posterior circumflex, as this must 
again be divided, and pressure on the subclavian readily 
commands it; both the outer and inner flap being now 
raised, the head of the bone may be rolled a little out- 
wards, and the teres minor and infra spinatus cut across 
upon it with a large scalpel, opening at the same time 
into the cavity of the joint ; by which means the error 
of slitting up the bursa under the acromion, instead of 
the capsular ligament, will be avoided, and continuing 
the incision upwards, cutting through the capsular liga- 
ment, the tendon of the supra spinatus, and the long 
head of the biceps flexor cubiti as close as possible to 
the edge of the glenoid cavity. The surgeon placing 
his fingers on the head of the bone, cuts through the 
inner side of the capsular ligament, and with it the sub- 



316 ELEMENTS OF SURGEUY. 

scapularis muscle, going to be inserted into the lesser 
tuberosity of the humerus. The edge of the knife being 
constantly towards the bone, he divides the under part 
of the ligament, separating the head of the bone from 
the glenoid cavity : resuming the small amputating knife, 
lie cuts through the long head of the triceps, to prevent 
its hanging too much into the wound, and then with one 
sweep he connects the points of the two first incisions 
underneath, separating the arm from the body, dividing 
again the circumflex arteries above the first incision, the 
teres major, latissimus dorsi, coraco brachialis, long 
head of the triceps, axillary artery, veins, and nerves. 
This beiug the only dangerous step of the operation, the 
surseon should inform himself if the artery be sufficient- 
ly compressed, which he will know by the posterior 
circumflex artery not bleeding, and the want of pulsation 
in the axilla : he should caution the assistant to pre- 
serve the steady position of the patient, and have another 
ready to press his closed hand upon the artery, if it 
should bleed. Laying down the knife, he takes the ar- 
tery if bleeding between the finger and thumb; or if com- 
pressed pulls it out with a tenaculum, and ties it firmly 
with a small ligature of two good threads. The vessel 
is found contracted amongst the nerves in the lower third 
of the wound ; all pressure being removed, the anterior 
and posterior circumflex arteries will bleed, and must 
be secured ; or, if the artery subdivides high up, there 
may be a fourth large branch. 

In recent cases of injury I have seldom had occasion 
to .take up more than three arteries, and no cutaneous 
or other vessels, besides those divided by the last inci- 
sion. The nerves, if hanging in the wound must be 
shortened, which though painful, prevents a source of 
irritation hereafter from their adhering in the neighbour- 
hood of the cicatrix. The axillary vein, if it continue 
to bleed, should be secured with a single thread, as it 



ELEMENTS OF SURGERY. 317 

allows some blood to pass into the wound after it has 
been brought together, and, what is of more material 
consequence, permits it to pass into the loose cellular 
membrane surrounding the vessels down to the clavicle, 
which may cause considerable mischief, as the position 
of the patient is favourable to its gravitation. 

All compression having been taken oif the artery, the 
wound should be well cleansed, and here a little delay 
may be allowed. If the tendon of the long head of the 
biceps flexor cubiti be left long, it ought to be cut ofl' 
with the scissars, as well as any ragged portions of the 
capsular ligament. The glenoid cavity need not be de- 
prived of its cartilage. The pecioralis major will be 
observed to have retracted considerably, aud to have 
doubled or folded in the skin covering it; through this 
(the parts being brought together,) a suture should be 
put to the opposite side, and the whole properly sup- 
ported and compressed by strips of adhesive plaster 
and bandage, the ligatures being brought out direct. 
The incision then forms but one line from the acromion 
downwards, curving at the bottom to the fore part of the 
chest, the skin at the axilla being always a little wrinkled, 
and much inclined to retract. The flaps of the deltoid 
meet firmly, sink a little into the hollow under the acro- 
mion, lie close upon the glenoid cavity and the coracoid 
process ; and from the pressure of the adhesive plaster 
and compress, with the evenness of the wound, the skin 
of this part nearly unites by the first intention ; the hol- 
low round the glenoid cavity is comparatively small to 
what might be expected, and the consolidation in healthy 
subjects, where every thing has done well, goes on 
steadily, so as not to leave any cause of future incon- 
venience. The surgeon, in all his dressings, should 
take care that no collection forms any w here by keeping 
up a regular and proper (.impression in the course 
of the artery, the coracoid process, the pectoralis major, 



318 ELEMENTS OF SURGERY. 

and the muscles from the scapula and back. The paiu 
and sensation principally complained of is from the hand 
and arm ; there is seldom any haemorrhage, and the pa- 
tient does not suffer more than in any other common 
amputation. 

I have insisted on the arm being raised from the first, 
because in all operations that require the principal artery 
to be compressed, it should not be done until the limb 
be placed in the situation in which the operation is in- 
tended to be performed, as the mere alteration of posture 
removes the pressure from its destined point, as must 
frequently have been observed, when the tourniquet is 
applied without this caution in the axilla, or thigh. 
This elevation also allows more freedom to the knife in 
every direction, and points out more clearly the situation 
of parts. I beg, however, to be understood as not re- 
commending the arm to be raised in secondary cases, 
when there is partial anchylosis, or thickening of the 
ligaments, or other fair obstacles to its being done with 
ease to the patient. 

It is not necessary to lay bare the acromion, on the 
contrary, the finger should be placed immediately upou 
it, to insure the first incision, being near half an inch 
below it, if the eye of the operator be not a sufficient 
guide ; the flaps turn aside sufficiently without it, the 
head of the humerus is extricated with equal ease, and 
there is no subsequent danger if the stump should slough, 
or of the acromion coming through and being a future 
inconvenience to the patient. 

In making the last incision of separation, care should 
be taken to save as much of the integuments as the na- 
ture of the operation will permit ; and this is done by 
keeping the head of the bone as far from the glenoid 
cavity as the attachment of the teres major and latissi- 
mus dorsi will allow, and by then cutting as close to the 
bone as possible. The long head of the triceps muscle 



ELEMENTS OF SURGERY. 319 

is divided before the last incision, to prevent its hanging 
too long in the wound, and interfering with the approxi- 
mation of the integuments. The anterior and posterior 
circumflex arteries require only a single thread ; the lat- 
ter will be divided about three quarters of an inch from 
its origin, and the axillary artery in general near an inch, 
from where it gives off the subscapularis. 

From Mr. Guthrie's statements it appears that the 
amputation at the shoulder, succeeds vastly better when 
performed on the field of battle, than when the patients 
are taken into hospitals. Of nineteen cases in which the 
operation was performed, soon after the wounds were 
received, one only died. — Whereas of an equal number 
of operations performed in the general hospitals, fifteen 
died, a strong argument in favour of promptness in all 
such cases. 

I have once been called to perform this operation in 
a case of fungus nematodes near the shoulder, and shall 
describe my mode of operating, which is that taught by 
Dr. Physick. — An assistant was charged to compress 
the subclavian artery, where it crosses the first rib — an 
incision was then made with a large scalpel, from the 
anterior to the posterior edge of the axilla, in a direc- 
tion somewhat curved downwards — this incision was 
only through the skin and cellular texture, which were 
dissected upwards from the deltoid muscle — another 
incision was next made in a straight line through the 
skin of the axilla, meeting the first — the joint was now 
cut into through the top of the deltoid — the head of the 
humerus luxated, and the amputation completed by 
passing the knife through the vessels, nerves, and other 
soft parts in the axilla — the axillary artery was evident 
at first glance, but did not bleed ; it was secured by a 
strong ligature, as were all the other bleeding vessels. 
The whole operation was over in eleven minutes, and a 
very small portion of that time was consumed in the 



320 ELEMENTS OF SURGERY. 

incisions. The flap was now brought down, and the 
edges of the skin were found to approximate very well — 
€i better flap could not have been formed in any other 
way.* It healed up very readily and my patient got 
well. 

From what I have seen and read on this subject, I 
cannot hesitate to believe that in a great variety of Mays, 
the arm may be safely amputated at the shoulder — the 
plan I selected was of course that which struck me as 
best adapted to the particular case. 

I have no doubt that the operation has often been per- 
formed without necessity. I have once amputated an 
arm torn off by a cannon shot, as high up as the axilla, 
I preserved a flap by retaining the integuments in such 
parts as appeared sound, and sawed through the bone in 
the usual manner, in this case the axillary artery was 
the only one which required a ligature. This case would 
in the opinion of many have warranted amputation at the 
joint, but it would have added much to the danger, pain, 
and confinement of my patient. 

That the operation becomes in some cases absolutely 
necessary I well know, and in such cases it should be 
performed in the manner recommended by Mr. Cline. 

With respect to the dressings, all that can be said is, 
that after the arteries are tied up, the flap is to be neatly 
applied over the joint, and kept in its proper position by 
adhesive plasters and a roller. 

* It would be as easy to include the deltoid in the flap, but this would be 

soon absorbed, and without being' useful, would render the operation more 

difficult from the blood vessels which would be cut, but in most instances the 

surgeon has no choice, and is compelled to make his flap, (if indeed he can 

' it at all) wherever there may be flesh enough left to afford him one. 



ELEMENTS OF SURGERY. 321 



CHAPTER XXXIX. 



Amputation at the Hip-joint. 

The dangers attending this tremendous operation have 
almost occasioned it to be laid aside. Mr. Pott declar- 
ed, after having seen it done, that he should never per- 
form it on the living body. 

A French surgeon by the name of Barbet, received 
a prize from the Academy of Surgery, for an essay ou 
the present subject in 1759. He considered it a neces- 
sary operation in three distinct cases. 1st, When the 
soft parts around the joint have mortified. 2dly, When 
a cannon ball has shattered the limb, in such a manner 
as to leave but a small portion of flesh to unite it with 
the trunk ; and 3dly, In cases where the femoral artery 
has been wounded near Poupart's ligament. 

The two first cases are happily rare, and yet they cer- 
tainly sometimes sanction and demand the operation. 
The third case is now treated in a very different manner, 
by tying the artery above the wound. Certain other dis- 
eases near the articulation may perhaps render the opera- 
tion necessary. 

Messrs. Pariset and Petit have written a short paper 
on this subject in the Dictionaire des Sciences Medica- 
tes, in which they declare that the operation has been 
successfully performed by two French surgeons, La- 
croix and Perault. 

Dr. Larrey has performed this operation oftener than 
perhaps any other surgeon ever did ; his patients have in 
most instances died, but I am informed that in three ca- 
Vol. H. T t 



322 ELEMENTS OF SURGERY. 

ses they recovered. It ought only to be performed when 
certain death is the alternative. 

It is evident that the circumstances demanding this 
operation must materially influence the mode of perform- 
ing it. The separation of the injured parts must be ef- 
fected in the simplest possible manner, and the blood- 
vessels carefully secured. Larrey in performing the ope- 
ration commences by tying the femoral artery as near as 
possible to the crural arch ; he then forms a flap on the 
inside — cuts down to the articulation — divides the cap- 
sular and round ligaments — dislocates the bone — forms 
an external flap of the glutaei muscles adapted to meet 
the internal flap — after which the arteries are tied up, 
and the parts brought together and dressed in the usual 
manner. 

As some of the principal vessels wounded in this ope- 
ration are the brandies of the internal iliac, it appears 
to me that in emaciated subjects it would be easy, for a 
time, to command the hemorrhage by compressing the 
aorta opposite the navel, and in most patients I believe 
this would diminish the loss of blood. 

The following remarks, taken chiefly from Mr. Guth- 
rie's treatise on gun-shot wounds requiring amputation, 
will convey to the reader the latest information on the 
present subject. The military surgeons are almost ex- 
clusively those who are called on to perform this opera- 
tion, and they have of late years, had several opportuni- 
ties of testing its value. 

" I have not much to oiler from actual experience of the 
operation, having performed it but once unsuccessfully. 
1 have however seen many cases in which it ought to 
have been attempted, and which died. I have seen 
many in which the operation would have been necessary, 
if the constitution of the patients could ever have re- 
covered the shock it had received at the moment of in- 
jury. I know that many cases have died after long con- 



ELEMENTS OF SURGERY. 323 

Untied disease of the thigh bone from gun-shot wounds, 
that would have had a chance of recovery, if the opera- 
tion had been performed ; and I have several times am- 
putated so close to the trochanters, that I could with 
ease have removed the head of the bone without any 
increase of the external incisions. 

This amputation is of course either primary or secon- 
dary ; but the nature of the injury or disease differs very 
much in these two stages ; for very few, or none of the 
cases that render its performance necessary on the field 
of battle, ever live to the period when secondary ampu- 
tation is usually recommended. 

Wounds demanding amputation of the hip joint on 
the field of battle, arise from cannon or grape shot, or 
the explosion of shells. Few surgeons would think of 
performing it for a wound by a musket ball, although 
cases may occur that require it, and the principal one 
that will render it necessary, will be a fracture of the 
head or neck of the bone, with a wound of the great 
vessels, or some other arterial trunk causing haemorrhage, 
and stuffing the thigh with blood. A grape or small 
cannon shot, may strike the fore part of the thigh, and 
without wounding the inguinal artery itself, may, in its 
passage to the neck of the femur, wound some large ar- 
terial branches, causing considerable haemorrhage : the 
wound shall not be large, and yet the chance of saving 
the life of the patient will be but very small indeed. I 
recollect two cases of this kind in particular ; one after 
the battle of Vimiera, by a cannon shot, which proved 
fatal on the second day after the injury, no one at that 
time thinking of the amputation at the hip joint. The 
other occurred at Salamanca, by a large ball, which 
shattered the neck of the femur and the body of the bone 
below. I did uot see this person for near forty eight 
hours after the injury, but was informed that on his first 
presentation for assistance, an artery, supposed to be a 



324 ELEMENTS OF SURGERY. 

large branch of the femoral, had thrown out its blood 
per saltum, and was stopped by pressing some lint on 
the wound. The limb soon swelled to nearly twice its 
natural size, with much external inflammation. The 
patient himself thought his case desperate, as did every 
one about him, and declared his willingness to submit 
to any operation that might be proposed ; but the time 
for operating was past, even if any operation could have 
been agreed upon. 

After two months of severe suffering, in which there 
were even some prospects of life being preserved, this 
man died. The latter period of the time was passed, 
however, without any hope of recovery, and surgical aid 
was given merely with the view of rendering his last 
moments as easy as possible. The great strength of 
constitution shewed by this man during the whole course 
of his illness, and his great endurance of suffering, have 
always inclined me to think the operation at the hip 
joint would have succeeded, if it had been performed 
shortly after the receipt of the injury. 

A shell bursting near a soldier may drive a large 
piece of an inch in thickness, and a pound or two in 
weight, into the inner part of the thigh, without wound- 
ing the femoral artery, yet fracturing the head of the 
bone: here several large vessels, and perhaps the great 
sciatic nerve would be divided, and the only chance of 
life, in my mind, would be in the immediate removal of 
the whole. I saw a fatal case of this kind during the 
siege of Ciudad Rodrigo, where the patient lived long 
enough to shew the necessity of performing this operation. 

A piece of a shell may strike between the trochanter 
and the ilium, go through the neck of the bone, and tear 
its way out below the tuberosity of the ischium, destroy- 
ing all the parts in its course, without either killing the 
soldier by haemorrhage, or by the shock of the blow to 
the constitution. This accident happened to a man of 



ELEMENTS OF SURGERY. 325 

the 40th Regiment, at the battle of Salamanca, about 
four o'clock in the afternoon. He was in a good state 
to undergo the operation when I saw him next morning, 
but none of the surgeons present with me would agree 
to it ; all allowed nothing could save the man ; but the 
opinion entertained of the cruelty of the operation, and 
of its certain failure prevented its being done. I took 
this man into Salamanca with me, and his appearance 
for six successive days before he died, made me reproach 
myself for my want of courage, in not contemning any 
remarks that might be made, on my having undertaken 
it in opposition to the opinion of my colleagues ; and I 
declined it, not because the general opinion was against 
it, but in consequence of the bad success of one, and of 
the good success of the other, of the two next cases to be 
related. 

When a cannon-shot carries away the thigh above its 
middle, so as to exclude the more common flap opera- 
tion close to the trochanter, it is almost always fatal. 
These accidents generally destroy at once. On the 
field of battle, 1 have seen many, having searched par- 
ticularly for them, but have found them dead, or beyond 
the reach of surgical aid. 

I have seen a case of a cannon-shot striking the out- 
side of the thigh, tearing away the trochanter and sur- 
rounding parts, without wounding the femoral artery, or 
any great vessel that would cause any serious haemorr- 
hage, or so great a shock to the constitution as to render 
the operation impracticable ; yet this man died without 
any attempt being made for his relief, which was neither 
good surgery nor humanity. 

When the femoral artery has been tern through by a 
cannon-shot there is, at the moment, a great loss of 
blood, but the patient does not bleed to death, neither 
does he appear to die ultimately from the effects of the 
haemorrhage : for I have seen several men lose a greater 



326 ELEMENTS OF SURGERY. 

quantity from the same vessel without any such effect, 
but from the shock to the constitution ; and this observa- 
ble in many cases of amputation of the thigh, where 
there has been little loss of blood ; and yet the patient 
dies, during, or immediately after the operation. A con- 
siderable haemorrhage, on the other hand, renders a pa- 
tient less able to bear an operation than he otherwise 
would do, and where there has been much and sudden 
bleeding, the powers of life are so exhausted as not to 
be able to bear any further disturbance. This effect is 
most frequently caused by wounds of the femoral artery, 
and where it lias occurred, the chance of success from 
the operation, will be very small : and the combination 
of injury arising from the loss of blood, and the shock 
of the blow, will have so much diminished the powers 
of life, that the operation in addition, will destroy the 
remainder. 

If (as I have seen in many instances) the bones of the 
pelvis are injured, in any of the preceding kinds of ac- 
cident, the result will be fatal, and the operation should 
not be performed ; but some little destruction of the soft 
parts, should not prevent it, if the patient be otherwise 
in a favourable state. 

A very extensive injury of the soft parts of the thigh, 
if the bone be not broken, and the femoral artery not 
divided, does not authorize the operation, although the 
artery be laid bare for three or four inches of its course. 

An officer of the 88th Regiment, was wounded in the 
trenches, at the siege of Ciudad liodrigo, by a twenty- 
four pound shot, which struck the outside of the ante- 
rior part of the left thigh, and carried aw ay the fore part 
of it from the groin to within a hand's breadth of the 
knee ; the femoral artery lay bare at the bottom of the 
upper part of the wound, and was seen pulsating for 
near three inches ; the sartorious and rectus muscles 
were carried away, and all the muscles on the outer and 



ELEMENTS OF SURGERY. 327 

inner side of the thigh more or less mangled by the shot, 
or torn by the laceration ; it was altogether the most 
frightful looking wound I had seen, not even excepting 
where the limb has been completely torn off'. Having 
the superintendance of the 3d and 4th divisions of in- 
fantry, the greater part of the medical officers of both 
were with me at the time ; and on this officer's being 
brought to our field hospital in the rear of the trenches, 
they all, without an exception, declared he must shortly 
die, if the limb was not removed. In compliance with 
this opinion, I proposed to tie the artery below Poupart's 
ligament, and to endeavour to save flaps to cover the 
great trochanter, the bone being sawed off below, as I 
have since done in several instances ; and if this was 
not practicable, the head of the femur was to be remo- 
ved. On placing him on the panniers for the purpose 
of operating, he was so exceedingly faint, the pulse at 
the wrist being scarcely perceptible, .that I conceived 
the operation would be useless, as he would certainly 
die under our hands. He was removed to a corner of 
the hospital, and placed on a hay mat amongst other 
cases of wounded supposed in a dying state, a little lint 
being laid over this enormous surface. By the next 
morning he had much recovered, and as his thigh be- 
came very painful, he was desired by the surgeon of the 
division arriving in succession, to wet it with warm 
water ; this was done, but his countenance was so ghastly 
that he was considered by every one as dying : indeed 
his regiment actually returned him dead, and his com- 
mission was filled up in England. In this state he re- 
mained till the day after the storming of Ciudad Rodri- 
go, when, from the advance of Marshal Marmont, the 
wounded were sent across the Agueda. Desirous of 
knowing whether any stragglers of the corps I belong- 
ed to fright still be at the field hospital, I rode to it on 
leaving the town, and found every one £;one except this 



328 ELEMENTS OF SURGERY. 

poor gentleman, who requested my assistance ; having 
conveyance in the town, I offered to take him to my 
divisional hospital, five leagues distant, where all the 
other wounded had been couveyed, which offer he 
gladly accepted, and reached the village of Aldea del 
Obispo, with less inconvenience than I expected ; I daily 
feared the femoral artery would give way, but nothing 
of the kind occurred, the slough from the whole surface 
of the wound soon separated, and there was much less 
of it than is usual on such occasions, but this may be 
attributed in some measure to the attention paid him, 
and to the extreme coldness of the weather in a room 
without a fire-place. The discharge of pus was very 
great, and the artery lay in a channel completely cover- 
ed by it; — I hourly expected it would ulcerate, but 
granulations soon began to shoot out, and by the end of 
three weeks the artery was covered in, although its pul- 
sations were still ^visible at a distance ; the sore gradu- 
ally contracted in a surprising degree, and in two months 
it was diminished to half its original size, very little new 
skin having been formed. At this period he left me on 
his way to the rear, on the army moving down to the 
siege of Badajos. The attention paid to this officer in 
regard to diet, attendance, and surgical aid, was very 
great ; more, indeed, than he could have received under 
any other circumstances. His recovery was considered 
so unlikely, that no one looked at his wound after the 
first day ; all supposed him past relief, as was really the 
case with an officer of Engineers, lying beside him. 
whose arm was shattered to pieces by a shell, and the os 
ilium bared on the outside of the glutaei muscles, and on 
the inside of the iliacus internus, as if it had been for 
some time in maceration. The insertions of the external 
and internal oblique, and the transversalis muscles were 
torn out without the peritoneum being opened, which alone 
prevented the intestines from coming out at the wound. 



ELEMENTS OF SURGERY. 329 

Although this gentleman's life was saved, still, I am 
of opinion, that very few would have recovered under 
the same injury. 

The secondary operation has seldom, I believe, been 
performed during the high suppurative stage succeeding 
to injury from gun-shot wounds ; and as 1 do not be- 
lieve it can be successful, if done at this period, I would 
not perform it after the second day, until the third or 
fourth week. There are not many cases that will de- 
mand it at this period, as the femur, in most compound 
fractures of the thigh, can in general be sawed off, at, 
or immediately below the little trochanter." 

The operation has been twice performed in England: 
in one case it was completely successful ; and in the 
other, the patient lived thirty days. 

" Mr. Brown rigg, Surgeon to the Forces, has per- 
formed the operation four or five times : on one occasion 
the patient lived eight days, and died from fever, sup- 
posed to arise from causes foreign to the operation. 

In the last case he was completely successful. The 
man received a gun-shot wound in the thigh, which 
fractured the bone close to the trochanter, on the 29th 
Dec. 1811, near Merida, in Spain. On the 12th of 
December, 1812, the operation was performed, and the 
man is now living at Spalding, in Lincolnshire, in per- 
fect health. 

Mr. Brownrigg intends, I believe, to publish the par- 
ticulars of this case. I have also been informed, that 
the operation has been performed in the West Indies. 

These cases prove, that the operation is not only ne- 
cessary, but practicable, and that it may be effected with 
success under certain circumstances. This being grant- 
ed, it necessarily follows that the operation ought to be 
recommended and performed in every case in which it 
can alone bring relief, or offer a prospect of success. 
No man should, therefore, be allowed to die without iu 

Uu 



330 ELEMENTS OF SURGERY. 

being proposed to him ; and if it be a case for primary 
operation, the sooner it is done on the field of battle, 
consistent with propriety, the greater will be the chance 
of success, for the patient cannot live to the period for 
secondary amputation. It is in this, and other opera- 
tions high iu the thigh, that the question of time is most 
important, for haste is as injurious as delay, when im- 
properly applied. 

If the patient has suffered much loss of blood, or is 
in a state of syncope, or nearly approaching to it, unable 
to articulate, with a pulse scarcely perceptible, and (he 
skin clammy and cold, an immediate operation would 
only hasten his death ; but if excited by stimulants and 
cordials, he will have some chance of recovering himself 
in an hour or two, so as to undergo the operation with a 
better prospect of success, or he will in that period sink 
and die. If, on the contrary, be is brought to the sur- 
geon, although much alarmed and reduced by the sud- 
den shock and loss of blood, with strong sensations of 
pain, expressed by his cries for assistance, convulsive 
motious of the limb and body, and the powers of the 
sensorium not destroyed, the operation should be per- 
formed immediately : or, instead of becoming more calm 
and collected, he will gradually sink into the state of 
the first descrihed, and be unable to bear the operation. 
On the other hand, the first mentioned, if he be excita- 
ble, will in time rather approach to the state of the lat- 
ter, and from the f>ain, &c. he suffers, will call for the 
performance of the operation. This violent nervous 
commotion, however, is not common ; it depends upon 
par icular idiosyncrasies, and will never in the first be 
so excessive as in the last. 

Ti=e operations being decided upon, it is, I confess, 
not like that at the shoulder-joint, to be done by every 
otte ofmodefate ability. >io surgeon should attempt it, 
unless he is conscious of possessing great coolness, a 



ELEMENTS OF SURGERY. 331 

presence of mind equal to any emergency, and a correct 
knowledge of the parts to be divided. 

I consider the operation to be best performed in the 
following manner. The patient should be laid on a low 
table, or two field panniers placed together, covered 
with a folded blanket to prevent the edges giving pain, 
and properly supported in a horizontal position. An as- 
sistant leaning over, and standing on the outside, should 
compress the artery against the brim of the pelvis, with 
a firm, hard compress of linen ; such as is usually used 
before the tourniquet ; he should also be able to do it 
with his thumb, behind the compress, if it be found in- 
sufficient. The surgeon standing on the inside, with a 
9trong pointed amputating knife of a middle size, with 
the back curved, makes his first incision through the 
skin, cellular membrane, and fascia, so as to mark out 
the flaps on each side, commencing about four finger's 
breadth, and in a direct line below the anterior superior 
spinous process of the ileum in a well- sized man ; and 
continuing it round in a slanting direction at an almost 
equal distance from the tuberosity of the ischium, nearly 
opposite to the place where the incision commenced. 
Bringing the knife to the outside of the thigh, he con- 
nects the point of the incision where he left oft* with the 
place of commencement, by a gently curved line, by 
which means the outer incision is not in extent more 
than one third of the size of the internal one. The in- 
teguments having retracted, the glutaeus maximus is to 
be cut from its insertion in the linea aspera, and the ten- 
dons of the glutaeus medius and minimus from the top 
of the trochanter major. The surgeon now placing the 
flat edge of the knife on the line of the retracted muscles 
of the first incision, cuts steadily through the whole of 
the muscles, blood-vessels, &c. on the inside of the 
thigh. The artery and vein, or two arteries and vein, 
if the profunda is given off high up, are to be taken be^ 



332 ELEMENTS OF SURGERY. 

tween the fingers and thumb of the left hand, until the 
surgeon can draw each vessel out with the tenaculum? 
and place a ligature upon it. Whilst this is doing, the 
assistants should press with their fingers on any small 
vessels that bleed. The surgeon then cuts through the 
small muscles running to be inserted between the tro- 
chanters, and those on the under part of the thigh, not 
yet divided : and with a large scalpel opens into the 
capsular ligament, the bone being strongly moved out- 
wards, by which its round head puts the ligament on 
the stretch. Having extensively divided it on the fore 
and inside, the ligamentiim teres comes into view, and 
may readily be cut through. The head of the bone is 
now easily dislocated, and two or three strokes of the 
knife separates any attachment the thigh may still have 
to the pelvis. The vessels are now carefully to be se- 
cured. The capsular ligament, and as much of the liga- 
mentous edge of the acetabulum may be removed as 
can readily be taken away. The nerves, if long, are 
to be cut short, the wound well sponged with cold 
water, and the integuments brought together in a line 
from the spinous process of the ilium, to the tuberosity 
of the ischium. Three sutures will in general be re- 
quired, in addition to the straps of adhesive plaster, to 
keep the parts together ; the ligatures are to be brought 
out in a direct line between the sutures, a little lint and 
compresses are to be placed over the wound, and on 
the under flap, to keep it in contact with the cotyloid 
cavity, and assist the union of the parts. A piece of 
fine linen is to be laid over them, and the whole retained 
by a calico bandage put round the waist, and brought 
over the stump. 

It is recommended to pare the bone of its cartilage; 
and if this could be readily done, I would willingly 
agree to it, but the cartilaginous surface of the acetabu- 
lum is not to be cut away without much difficulty and 



ELEMENTS OF 9UHGERY. 333 

some time, which cannot be spared : for I consider the 
success of the operation to depend very much upon the 
quickness with which it is performed, not on account of 
haemorrhage, but to avoid the shock the constitution re- 
ceives from the continued exposure and irritation of so 
large a surface in the immediate vicinity of the trunk 
of the body. It is proved by experience to be unneces- 
sary at the shoulder joint ; and will, I think, be found 
equally so at the hip joint. 

When I wrote these observations, and shewed the 
method of performing the operation in the Peninsula, I 
thought I was the first to recommend that the artery 
should not be tied previous to commencing the opera- 
tion. M. Baffbs, however, has the priority in practi- 
sing it, which I readily grant to him, and am gratified 
in having his authority to adduce in support of the 
measure. 

Union by the first intention is to be wished for in a 
great degree, as lessening the surface of the wound ; but 
as all the parts beneath the skin cannot unite, and espe- 
cially about the acetabulum and the inside of the glutasus 
muscle, it is not advisable to let the skin adhere on the 
middle and lower part of the stump ; for as the parts 
deep-seated must suppurate and granulate, a fair open- 
ing for the discharge should be preserved, and collec- 
tions of matter in any part should be carefully guarded 
against by gentle pressure, compress, and bandage. 

The after treatmeut will be the same as in other cases 
of amputation : the shock, however, of the injury and 
the amputation will be so great, that the antiphlogistic 
regimen to the extent of blood-letting will not be neces- 
sary. If the patient be very low, cordials in small 
quantities, with opiates, should be given, and a light 
nourishing diet. If inflammatory symptoms come on, 
the appropriate remedies formerly recommended must 
be employed without delay. If there be heat or un- 



334 ELEMENTS OF SURGERY. 

easiness in the wound, it must be kept wet with cold 
water. 

If the surgeon called upon to perform this operation, 
has not been in the habit of dealing with large arteries, 
he may feel an unconquerable repugnance to cutting 
through the femoral artery before it has been tied ; and 
although I can most positively assure these gentlemen, 
there is nothing to fear in doing it, still they may tie the 
artery first, if they cannot overcome this feeling of dan- 
ger. It is to be done by cutting through the integu- 
ments in the usual manner, and then dissecting for the 
artery and vein, previous to cutting through the mus- 
cles\" 



ELEMENTS OF SURGERY. 



335 



CHAPTER XL. 



Amputation of the Fingers and Toes. 

The fingers and toes are generally removed at the 
joints. The operation is very simple when the structure 
of the joint is known. The skin should be moderately 
drawn back, and a circular incision made through it a 
little beyond the joint. A portion of skin is next de- 
tached with the scalpel sufficient to cover the stump. 
This little flap being reflected, the tendons and soft parts 
are to be cut down to the joint. The joint is now bent 
and the capsular ligament divided posteriorly, after which 
one of the lateral ligaments is to be cut through ; the 
bones now easily separate and the scalpel can be passed 
between to complete the division of the connecting parts. 
After this is done the flap is brought forward, its edges 
neatly approximated, and secured by a strap of adhesive 
plaster, after which a narrow roller is to be bound round 
the stump. The bleeding generally ceases after the 
dressings are applied, but if not it is easy to take up the 
vessels. A new mode of amputating fingers is described 
by Mr. Charles Bell, but it is less simple and no better 
than the one I have mentioned. 

The removal of the metatarsal and metacarpal bones 
in an operation described by many writers, hut one which 
is rarely necessary. I believe it will be found easier in 
most cases to cut down to the diseased bone, and remove 
with a trephine or saw resembling Mr. Hey's the af- 
fected pari. 



336 ELEMENTS OF SURGERY. 



CHAPTER XLI. 



Of Hemorrhage after Amputation. 

It not unfrequently happens that a discharge of 
blood takes place from the stump after amputation. It is 
consequently of importance to leave a careful assistant 
with the patient, and a loose tourniquet applied on the 

limb. 

The most frequent cause of secondary hemorrhage is 
the omission to tie up some artery which did not bleed 
immediately after the operation, owing to the langour of 
circulation, and the coldness of the stump from exposure 
which occasions a temporary contraction of the vessels ; 
the heat being restored and the circulation excited these 
vessels pour out blood. To obviate this inconvenience 
it is right to give the patient wine and water before the 
dressings are applied, and to wait a short time in order 
to ascertain whether the vessels will bleed. 

Another cause of bleeding after amputation is an im- 
proper degree of tightness in the circular bandage, which 
intercepts the return of blood through the cutaneous veins. 
Of course in cases of secondary hemorrhage a careful 
attention should be paid to the bandage surrounding the 
limb. 

Bleeding sometimes takes place from the medullary 
artery passing through a bone. I once saw a very trou- 
blesome hemorrhage of this sort, which was finally ar- 
rested by the introduction of a small cedar plug into the 
bony canal which afforded a passage to the vessel. 

Sometimes the bleeding results from the slipping off 
a ligature which had been carelessly tied. This event 



ELEMENTS OF SURGERY. 337 

should be guarded against by great care in securing 
every considerable vessel with a double knot. 

The bleeding sometimes also depends on a morbid 
condition of the system which is incompetent to those 
functions necessary for the restoration of the wound- 
ed parts. In this case the flap and stump will not 
reunite, and the arteries like the other parts will refuse 
to heal. This is only to be prevented by general reme- 
dies adapted to the constitution. 

In many cases the bleeding from a stump is so trifling 
as to give no serious alarm, but there are cases in which 
the loss of even a small quantity of blood is dangerous, 
and others in which so much is lost as to occasion great 
uneasiness. In these cases moderate pressure constant- 
ly continued by the hands of assistants may be tried, and 
in some instances this method prevents the uupleasant 
necessity of removing the dressings and exposing the 
stump. If it be not however successful the bleeding 
vessels must be carefully sought for, and secured by li- 
gatures. 

There is another kind of secondary hemorrhage which 
results from ulceration of the larger arteries ; this may 
occur at a remote period from the operation, sometimes 
a month has previously elapsed. It is, however, ex- 
tremely rare, and admits of no remedy but cutting down 
to the vessel and tying it up, or if this cannot be done, 
the trunk from which it proceeds should be tied. 

Mr. Hey has performed a singular operation with a 
view to arrest the secondary hemorrhage, and he says 
with success. I shall state his observations. "I have 
seen a few instances of the integuments becoming so con- 
tracted after the operation as to compress the veins just 
above the extremity of the stump, and bring on after 
some hours copious hemorrhage. AVhen it has appeared 
clear to me that the hemorrhage was venous I have made 
a division of the integuments on one side of the thigh 
Voi ,. IT X x 



338 ELEMENTS OF SURGERY. 

sufficient to remove the stricture, and this method has 
immediately suppressed the hemorrhage." 1 have my- 
self never seen such a case and therefore offer no opinion 
on the propriety of the practice. I shall subjoin from 
Mr. Hey a few more observations on the present sub- 
ject. 

" When we are under the necessity of amputating a 
limb that has suffered great contusion, though the opera- 
tion is performed upon a part apparently sound, the- 
wound sometimes becomes sloughy, and ill-conditioned. 
No good granulations arise to cover the extremities of 
the arteries, but the ligatures cut through these vessels, 
or becoming loose, cease to make a sufficient pressure 
upon them, and hence repeated hemorrhages ensue. This 
is a dangerous state for a patient ; for if the vessels are 
taken up afresh with the needle, the hemorrhage will 
now and then return in the course of two or three days. 
In such cases the application of dry sponge, cut trans- 
versely, as directed by Mr. White,* has been found sin- 
gularly useful, and has saved the life of the patient. But 
a constant pressure must be kept upon the pieces of 
sponge, by the fingers of a succession of assistants, till 
granulations begin to arise upon the stump, and the pros- 
pect of future hemorrhage disappear. This method is 
of the greatest importance after amputation on the thigh 
or leg, where the great vessels are deeply seated. In 
the arm, above the elbow, where the vessels are more 
superficial, the great artery may be taken up, with a por- 
tion of muscular flesh, above the surface of the stump, 
by making first an incision th rough the integuments. JVIy 
colleague Mr. Logan has done this twice within the last 
year, with complete success, when repeated ligatures, 
applied in the usual way, had failed. 

" In the morbid sloughy state of the stump above-men* 
tioned, the application of lint soaked in a liquid, com- 

* See Cases in Surgery, by Charles Whie, F. I 



ELEMENTS OF SURGERY. 



339 



posed of equal quantities of lemon juice and rectified 
spirit of wine, has been found very advantageous, and 
has caused the stump to put on soon a healthy aspect." 

It is recommended to apply cold lotions in those cases 
in which the hemorrhage appears to proceed from one or 
more small vessels ; cloths wet with a solution of sugar 
of lead may he placed upon the dressings and renewed 
from time to time as they become warm. 

The use of styptics and astringents can never be ap- 
plied with propriety to the surface of a stump. The 
agaric formerly employed, is never used at the present 
day. Mr. Petit contrived an instrument for the pur- 
pose of compressing the whole surface of a stump after 
amputation. To prove the importance of his inven- 
tion, he relates a case in which a thigh was amputated, 
and the femoral artery was found ossified, and could not 
be secured by a ligature ; his complicated machinery was 
applied and arrested the hemorrhage ; this contrivance, 
however, has sunk into deserved neglect, and no confi- 
dence should be placed in any similar machine. 

Upon the whole, the best mode of preventing trouble 
from hemorrhage after amputation, is to secure carefully 
every bleeding vessel by a ligature. 



340 ELEMENTS OF SURGERY, 



CHAPTER XLII. 



Of Spasms of the Stump. 

It often happens that spasmodic motions in the mus- 
cles of the stump take place after amputation, which are 
attended with extreme pain. They sometimes continue 
for several days, and now and then affect the whole 
body : in some instances death has resulted. 

The present modes of operating are supposed to have 
diminished the frequency of these unpleasant conse- 
quences, but they still occasionally happed. The best 
mode of relieving the pain and of preventing injury to 
the stump, is to have it held by a succession of assist- 
ants, and to administer liberal doses of opium. 

In cases in which amputation is performed on persons 
addicted to habits of intemperance, the administration of 
opium is always proper to prevent the occurrence not 
only of spasm, but of delirium, and death ; this remark 
however is equally applicable to all surgical operations 
under similar circumstances. Volatile alkali and other 
stimulating articles are also useful medicines in these 
instances. 



ELEMENTS OF SURGERY. 341 

CHAPTER XLIII. 

Extirpation of Tumours. 

One of the most eloquent compositions contained in 
our medical libraries is the treatise upon tumours con- 
tained in Mr. John Bell's Principles of Surgery; having 
very freely censured this writer in a former chapter, I 
take great pleasure in applauding where I have so fair 
an opportunity. To his treatise therefore I refer my 
readers for a most elabovate and instructive history of 
our present subject. The limits allotted to this work 
prevent me from entering extensively into it, and I 
shall in general terms advise the early removal of all 
tumours which constantly increase in growth — which 
after being indolent become painful — or which are 
situated in parts where their enlargement or ulcera- 
tion would occasion an interruption to any of the func- 
tions of the body. 

Encysted tumours which in popular language are 
called wens, ought to be cut out, for although they have 
no ten(rency to end in cancer and do not often ulcerate, 
yet they encrease occasionally to an enormous size. 
They consist of an external bag or sac, containing either 
fat, in which case the tumour is called steatomatous, or 
a substance resembling honey termed meliceris, or a soft 
pappy substance called atheroma. Commonly these wens 
are not deeply seated and are moveable, in which case 
they arc very easily taken out. The operation consists 
in making an incision through the skin down to the tu- 
mour, and dissecting round it, carefully avoiding an 
opening into the sac. The method of dissecting out a 



342 ELEMENTS OF SURGERY. 

cancerous breast, is applicable to most encysted tu- 
mours. The skin to be saved must be sufficient to cover 
the wound, but it is inconvenient to leave more and there- 
fore where the tumour is large, two incisions are to be 
made meeting like two segments of a circle, or the marks 
of a parenthesis (). 

Fleshy or sarcomatous tumours have been the sub- 
ject of a very valuable essay by Mr. Abernethy. He di- 
vides them into a number of classes which I shall not 
enumerate, because the knife is the safest and least pain- 
ful remedy for them all. 

Great improvements in surgery have resulted from 
the boldness with which large arteries are tied up, among 
others, the extirpation of tumours is greatly facilitated 
by securing those vessels which may be liable to injury, 
before the operation, Mr. Groodlad, secured for example, 
the carotid, previously to cutting a tumour from the face. 
It is often sufficient however, to expose the vessel so as 
to place it under the command of an assistant. 

The surgeon should prefer the early extirpation of tu- 
mours, but he is not to be deterred by their future growth 
from dissecting them out. A very large tumour was safely 
and successfully removed from a man's neck and face by 
Dr. Physick in the Pennsylvania Hospital. The weight 
of this tumour was seven pounds, its circumference twen- 
ty-three inches at its base, and twenty-five aifi a half 
inches at its largest part. It involved the parotid duct 
which was divided in the operation. The patient soon re- 
covered, and was discharged cured. Previously to the 
operation he appeared like a man with two heads. 

In order to prove that the size of a tumour furnishes 
no objection to its removal, I shall insert a case, from 
the American Philosophical Transactions. I believe it 
to have been the largest steatomatous tumour ever suc- 
cessfully removed from the human body. A French 



PLATE XXV 





J.S.J>,r.. 



ELEMENTS OF SURGERY. 343 

surgeon Mr. Dela Croix, extirpated a diseased testicle 
Weighing 29 pounds, but this was an entirely different 
operation. 

CASE. 

The patient, Julia Richards, a negro woman, from 
Carlisle, in Pennsylvania, was aged about forty-five 
years, and enjoyed good health ; she was corpulent, but 
active, until her exertions were restrained by the in- 
cumbrance of her tumour. 

She stated that it had been first noticed about eighteen 
years before I saw her ; — that it had grown gradually, 
and had never been painful. When she applied to me, 
her attitude in walking resembled that of a woman carry- 
ing a large and heavy sack. On examination, I found 
the tumour arising at the upper part of the back, extend- 
ing equally on both sides, and although pendulous from 
its weight, yet the root of it was very large. The di- 
mensions were as follow : 

Circumference at the neck or narrowest part of the 
tumour, two feet ten inches. 

Circumference at the thickest part, vertically, three 
feet nine inches. 

Circumference horizontally, three feet one inch and a 
half. 

The circumference of the waist after the wen was re- 
moved, was two feet nine and a half inches, so that the 
narrowest part of the tumour was thicker than the pa- 
tient's body. 

The surface of the tumour was tolerably regular, but 
very large and numerous veins were seen in various 
parts of it. 

The patient was admitted into the Pennsylvania Hos- 
pital, and on the 22d of February, 1815, I proceeded 



344 ELEMENTS OF SURGERY. 

to remove the tumour. Having previously administered 
an opiate, I placed her (at the suggestion of Dr. Phy- 
sick,) on her face upon the table, fifteen minutes before 
commencing the operation, and directed assistants to 
elevate the tumour in such a manner as to empty it as 
completely as possible of blood, and 1 was greatly de- 
lighted to perceive the change in the size of the super- 
ficial veins, which resulted from this simple expedient, 
many of them contracted and could not be perceived. 

The operation was commenced bv » xternal incisions 
calculated to preserve skin enough to cover the surface 
left by the removal of the tumour, and in being 

dissected and turned back, which was the most ted 
part of the operation, the tumour by large and rapid in- 
cisions, was detached from its base and ren 1 * d 
adhered to some of the spinous processes of the vei , 

and to the muscles and tendons near the spine. The 
operation occupied twenty- one minutes ; and '.:.; I 

blood was very trifling. — The skin was iouraf to i 

itself very well to the denuded parts, and was secured 
by strips of adhesive plaster, compresses and bandages, 

The greater part of the sore united by the first inten- 
tion ; no unpleasant symptoms occurred, and the patient 
was discharged cured, on the 15th April. She is at 
this time, and has been ever since the operation, per- 
fectly well. 

The tumour was found to weigh twenty-five pounds, 
but when filled with blood, was probably much heavier. 

The tumour of Eleanor Fitzgerald, described by Mr. 
John Bell ; and that of a negro woman, published in the 
Medical Repository of New York, (Vol. III. New Se- 
ries) were of enormous magnitude, but adherent by small 
bases. The basis in the present instance was very ^reat, 
and I am not aware that so large a tumour has been ever 
before extirpated. 



ELEMENTS OF SURGERY. 345 



REMARKS. 



The most important practical precept derived from 
this case, is the influence of position on the circulation 
of the blood. I once attended an operation on a tumour 
of comparatively small size, seated on the back, the ex- 
tirpation of which was found impracticable, in conse- 
quence of bleeding from the superficial veins. In the 
treatment of hemorrhagy from blood vessels in the ex- 
tremities, and on certain local inflammations, an elevated 
position is often found of great importance. I have seen 
a bleeding from an artery in an aneurismal arm, in 
which circumstances precluded the use of a ligature or 
tourniquet, effectually arrested by an elevated posture, 
the hand being constantly kept in a vertical position. 

These remarks, although somewhat digressive, are in 
my opinion of too much importance to be omitted. The 
practice of employing position to empty blood-vessels 
for surgical purposes, in the case alluded to, and others, 
so far as I know, originated with Dr. Physick, and my 
own experience has afforded numerous proofs of its 
value, and convinced me that it has been too much ne 
glected by surgeons. 



Vol. II. Y y 



•346 ELEMENTS OF SUIH. 



CHAPTER XLIY 



Of Warts and Corns. 

Most persons are acquainted with the usual appear- 
ances of warts. They are generally situated in the 
hands and lingers : they are a sort of excrescence com- 
posed of fibres projecting from the cutis vera, or parts 
below. They do not acquire a large size, but sometimes 
become irritable and painful, and when scratched or 
bruised they bleed and occasionally ulcerate. 

The best method of treating them is by stimulating ap- 
plications : such as tincture of cantharides,-strong vine- 
gar-caustic volatile alkali,-ihe various escharotic salts, 
as corrosive sublimate,-blue vitriol ; and if these fail, the 
wart should be destroyed by means of lunar caustic, or 
nitric, or sulphuric acid. 

Corns are as familiarly known as warts ; the former 
fashion of tight shoes has crippled a great many belles 
and beaux of the last age.' 

Corns are generally situated on the joints of the toes, 
and consist in a great induration of the skin, sometimes 
extending into the cellular substauce below. At times 
they are indolent, but irritation in walking excites great 
pain, and changes of the weather in some persons, al- 
ways occasion extreme pain. 

To relieve'thc inconveniences of corns it is essential 
that the patient wear loose and soft shoes. When the 
corn i* covered with a mass of thickened cuticle, the foot 
should be soaked in warm water, and this cuticle pared 
off. A very excellent mode of defending the corn from 



ELEMENTS OF SURGERY. 347 

the pressure of the shoe, when the patient walks, is to 
spread several small pieces of leather with adhesive 
plaster ; in the centre of these leather strips, a hole is to 
be cut rather larger than the corn. They are to be ap- 
plied successively over the toe or foot in such a manner 
that the corn shall he surrounded by the leather, and 
the shoe will then press upon the leather, the corn re- 
maining untouched. When situated on the sole of the 
foot, a felt or cork sole should be worn with a hole cut 
in it opposite to the corn. 

Mr. 8. Cooper states that a corn may be infallibly 
cured by the following method. " The corn is to be 
rubbed twice a day with any emollient ointment, and 
in the interim it is to be covered with a softening plas- 
ter. Every morning and evening the foot is to be put 
for half an hour in warm water, and whilst there the 
corn is to be well rubbed with soap ; afterwards all the 
white pulpy outside of the corn is to be scraped on", 
taking care not to give the least pain. The same treat- 
ment is to be continued without interruption until the 
corn is totally extirpated, which generally happens in 
eight or twelve days." 



J4& ELEMENTS OF SURGERY. 



CHAPTER XLV. 



Of the Inverted Toe nail. 

A disease frequently occurs in the great toe, produc- 
tive of more inconvenience and distress than the worst 
coins ; — an inversion of the nail of the great toe which 
grows in upon the flesh ; generally in consequence of 
wearing a tight shoe. 

This complaint is attended with severe pain and in- 
flammation, sometimes with ulceration, a fungus arises in 
many cases which is extremely sensible, and gives great 
p^in when touched, so that the patient is completely in- 
capacitated from walking. The nail in many cases be- 
comes completely imbedded in the flesh, and in others 
a thick skin forms over the greater part of it. Distress- 
ing spasms occasionally result. 

In general, persons afflicted in this way, are in the ha- 
bit of cutting the nails short, and interposing lint between 
the flesh and its edge ; but this does not retard the pro- 
gress or remove the pain of the complaint. The use of 
caustic is also ineffectual, and although it removes the 
fungus, yet this is speedily reproduced. 

Desault published a memoir on this complaint, and 
his curative indication consisted in keeping the nail and 
flesh separated. He effected it by taking a plate of tin, 
an inch and a half long, and about a quarter of an inch 
wide, and introducing it between the tumefied flesh and 
the edge of the nail ; he afterwards raised up the nail by 
depressing the flesh, which served as a point of support 
to the plate, and which was covered with a small com- 
press spread with cerate, to defend it ; then he bent back 



"ELEMENTS OF SURGERY. 349 

the plate from within outward, in such a manner as to 
embrace exactly the prominence formed by the flesh, and 
secured it by a small bandage rolled around the toe. 
After this the foot was poulticed. 

This operation succeeded with Desault, but he states 
that it is exceedingly painful, and as the process must 
be repeated daily, the pain is repeated as often. I there- 
fore take the liberty to recommend a simpler, easier, and 
more effectual remedy, — the excision of the inverted edge 
of the nail. 

Before commencing the operation, the foot should be 
soaked in warm water to soften the nail ; with a sharp 
strong bistoury the nail is to be slit down near the 
edge completely to the root, this portion is then to be 
carefully, but quickly, detached from the soft parts, after 
which a poultice is to be applied. The whole success 
of the pperation depends on removing radically every 
vestige of the nail at its root, after which the parts readi- 
ly heal, and a radical cure is effected. The relief pro- 
cured by this operation is hardly credible by those who 
have never witnessed it. It is well however for the sur- 
geon to be aware, that itis an operation as painful as al- 
most any he will be called on to perform, and therefore he 
should complete it as speedily as maybe consistent with 
a certainty of removing the whole offending part. 



150 ELEMENTS OF SURGERY, 



CHAPTER XL VI. 



Of Paracentesis Abdominis. 

The operation of tapping the abdomen in cases of 
dropsy, is performed usually by introducing a trochar 
through the parietes of the abdomen, through the canula 
of which the water is allowed to escape. The place at 
which this puncture has been made, until within a few 
years, was at the middle of a line drawn from the umbi- 
licus to the superior anterior spinous process of the os 
ilium. The left side was chosen to avoid the liver. It 
has however happened in several instances that the epi- 
gastric artery pursuing an unusual course has been punc- 
tured in this operation ; and, in other instances, the tro- 
char instead of perforating the linea semilunaris, as was 
intended, has pierced through the thick muscular pa- 
rietes of the belly, and occasioned much pain and in- 
flammation. This mode of operating, therefore, has 
been universally deserted, and surgeons now insert the 
trochar through the linea alba, two or three inches. be- 
low the navel, in a direct line towards the symphysis 
gmbis. 

The opening may very conveniently be made with 
a common trochar, or with a flattened trochar, but Dr. 
Physick has in my opinion greatly improved the ope- 
ration, by substituting for the trochar a lancet, which 
makes a clear incised wound, through which a flattened 
canula is inserted. The incision heals readily without 
inflammation. 

The most convenient mode of performing the opera- 
,f m is, to place the patient near the edge of the bed, and 



ELEMENTS OF SURGERV. 351 

under him a piece of oil cloth to prevent the fluid from 
wetting the bed clothes. The lancet is then inserted 
through the parietes of the abdomen, about two inches 
below the navel, and as soon as it is removed the canula 
is introduced. To prevent the edges of the canula from 
irritating any of the abdominal viscera, a smaller one clo- 
sed at the extremity and terminating in a smooth polish- 
ed surface perforated with several holes, is to be intro- 
duced after the water has flowed a short time. If these 
canuhe, however, be not at hand, a common female silver 
catheter and a lancet may be substituted, and with these 
instruments the operation has frequently been very well 
performed. Tn order to prevent the unpleasant effects 
which sometimes result from the sudden removal of the 
water, it is necessary after a portion has flowed out, to 
compress the belly in various places, by means of the 
hands of assistants, or bj r passing a sheet round the ab- 
domen, the two ends of which are to be drawn by assist- 
ants, and after the operation is completed to apply a 
bandage moderately tight round the abdomen. The 
current of Mater sometimes suddeuly stops before the 
whole of it is discharged, in consequence of a portion of 
intestine or omentum getting before the aperture of 
the canula, this is to be removed by introducing a probe 
or director. The fluid is sometimes too viscid to flow 
through the small apertures of a female catheter, in 
which case they must be enlarged, or a canula intro- 
duced open at the extremity. The only dressing the 
wound requires is a dossil of lint, or a strip of adhesive 
plaster. 

It is generally necessary in cases of dropsy to repeat 
this operation frequently. In these cases the puncture 
should never be twice made in precisely the same spot, 
because it has happened that adhesion has formed, con- 
necting an intestine to the cicatrix, and the intestine has 
been wounded in a subsequent operation. 



352 ELEMENTS OF SURGERY, 

Dropsy of the ovaria is a case sometimes demanding 
paracentesis. The tumour in this case commences on 
one side, and seems to rise out of the pelvis ; gradually 
enlarging, it at length fills the greater part of the abdo- 
men, and in its latter stage cannot from its appearance 
be distinguished from ascites, which from the beginning 
is attended by an equal, uniform swelling of the abdo- 
men. 

The cyst of the ovary which r.ntvta.ins the fluid in ova- 
rian dropsy commonly adheres in various places to the 
peritoneum so that there is no particular danger in tap- 
ping it. The operation is to be performed in the same 
manner as in ascites, and generally in the same place ; 
but if one part of the abdomen be more prominent than 
the rest in ovarian dropsy, the lancet should be inserted 
at that part. It only palliates the disease, and must in 
general be frequently repeated. Le Dran in some cases 
laid open the cyst of ovarian dropsies. His patients sur- 
vived and were cured of the dropsy, but a fleshy tumour 
formed, which gradually increased and destroyed the pa- 
tient, or else incurable fistulous ulcers remained. 

Attempts have been made to cure this complaint by 
injecting wine after evacuating the cyst, as in cases of 
hydrocele, but death has generally resulted, sometimes 
from the inflammation immediately subsequent, and at 
other times a more lingering termination has taken place. 

The seton has also been tried without success, and 
the best plan I believe is to evacuate the water occa- 
sionally in the manner which has been described. 

Paracentesis is sometimes but very rarely necessary 
for the evacuation of air in cases of Tympanites. It may 
be performed in the same way as for the evacuation of 
water. 



ELEMENTS OF SURGER*; 353 

CHAPTER XLVIL 

Par ace n tes is Thorac is . 

The thorax is sometimes opened for the purpose of 
discharging water, air pus, or blood, which may have 
collected from accident or disease. 

The manner of performing this operation is essentially 
different from that of tapping the abdomen. The place 
at which to make the aperture is, between the sixth and 
seventh true ribs, equi-distant from the spine and sternum. 
An incision about two inches long is to be made through 
the integuments of this part with a common scalpel; the 
intercostal muscles are next to be carefully cut through 
by an incision smaller than the external one. The pleu- 
ra costalis is now exposed, and a small puncture may be 
made through it. Water, air, pus, or fluid blood, will 
readily escape through a small aperture, but if coagula 
be found the incision must be enlarged. In order to avoid 
the intercostal artery, it is safest to cut through the mus- 
cular flesh close to the upper edge of the lower rib. In 
order to evacuate the fluid, the patient after the puncture 
should place the wound in a depending posture, by lying 
on his side. After the evacuation of the contents of the 
pleura, the wound is to be closed, and dressed with ad- 
hesive plaster. 

Mr. Riclierand of Paris, has proved in a very bril- 
liant and successful operation, that the thorax may be 
freely opened by removing portions of the ribs, if requi- 
site, for the removal of cancer. He proposes in cases 
of dropsy of the pericardium, to cut down to this sac, 
Vol. II. Z z 



354 ELEMENTS OF SURGERY. 

and evacuate the water. This operation has never been 
performed ; but in a clearly marked case (if such could 
occur) may certainly be regarded as practicable, and 
Mr. Richerand's opinion that the heart and pericardium 
might be made to adhere, as the testicle and tunica va- 
ginalis, in cases of hydrocele, is not void of plausibility. 
I regret that I received his interesting memoirs too late 
to notice it in its proper place. 



ELEMENTS OF SURGERY. 355 



CHAPTER XL VIII 



Of Bloodletting: 

For the cure of numerous morbid affections, blood 
must be evacuated. The means of drawing blood in use 
among medical men are several. 

General bleeding is performed by opening a vein, an 
operation called phlebotomy or venesection, and the punc- 
ture of an artery called arteriotomy. 

Topical or local bloodletting is performed by means of 
leeches : by opening the vessels of a part with a lancet 
or knife ; and by cupping. 

Phlebotomy or venesection is the most frequent 
and one of the simplest of surgical operations. 

It is usually effected by opening a vein in the arm. 
A band or ligature is to he applied around the arm be- 
tween the vein to be opened and the heart ; in conse- 
quence of this ligature the vein swells and becomes tur- 
gid ; the bandage, however, should never be draw • 
tight as to intercept the blood by the arteries, and it will 
A\. 'previously to applying the ligature, to feel foi 
i of the artery in order to learn its precise situa- 
tion. A vein is now to be chosen sufficiently turgid and 
superficial, and sufficiently remote from the artery; this 
vein is to be opened by a lancet, or German fleam. If 
the lancet is to be used (and most surgeons recommend 
it) it should be exceedingly sharp, in which case the 
shape of it is not so important as many have supposed, 
since it is easy with a very sharp lancet to make an 
aperture of any requisite size in the vein. When the lan- 

riirht hand, the thumb of tho 



356 ELEMENTS OF SURGERY. 

left hand is to be placed on the vein a little below 
where the puncture is to be made in order to fix the 
vein, but care should be taken not to alter the relative. 
position of the skin and vein, because in regaining this 
position after the lancet is inserted, the aperture through 
the skin will no longer correspond with, or be opposite 
to that in the vein, in consequence of which a thrombus 
or ccchymosis will form — a very common accident in ve- 
nesection. The lancet is to be pushed into the vein, and 
when its point is within the cavity of the vessel it is to 
he carried forward a little, so as to enlarge the opening 
sufficiently. The arm is to be kepi extended after the 
operation until the necessary quantity of blood is taken. 
If the blood should not flow as freely as is desired, the 
patient should exert the muscles of the arm by grasping 
a stick, or moving Cue fingers. 

After the blood is drawn the arm is to be wiped, and 
the sides of the orifi.ee neatly approximated in the man- 
ner directed by Mr. Hunter, which has been described 
in the chapter on wounds of veins, vol. 1. page 100. 

The external jugular vein is sometimes opened. The 
head should be kid on one side, and the vein is to be 
compressed by the surgeon's thumb near the clavicle, 
and the opening made in that part of the vein which lies 
over the sternocleidomastoid muscle. The blood soon 
ceases after the pressure is removed, but a small strip of 
adhesive plaster is sometimes necessary. 

Veins in the legs and feet can sometimes be found in 
children when there are none visible in the arm. To 
promote their distention, and to encrease the bleeding 
from them it is useful to immerse the limb in warm wa- 
ter. 

The German fleam or spring lancet I prefer greatly to 
the common English lancet for phlebotomy : it is now in 
some pai e United xclnsively used. 

J shall inserl some remarks on I which I pub- 



ELEMENTS OF SURGERY. 357 

lished in an edition of Cooper's surgical dictionary in 
1810. «In a country situated like the United Sf 
where every surgeon, except those residing in our largest 
cities, is compelled to be his own cutler, at least so far 
as to keep his instruments in order, the spring- lancet has 
a decided preference over the lancet; the blade of this 
can with great ease be sharpened by any man of common 
dexterity, and if not very keen it does no mischief, 
whereas a dull lancet is a most dangerous instrument ; 
and no one can calculate with certainty the depth to 
which it will enter : to sharpen a lancet, is regarded by 
the cutler as one of his nicest and most difficult jobs ; it 
is one to which few r surgeons are competent. 

" r J he safety of using the fleam is demonstrated by 
daily experience ; there is no country in which venesec- 
tion is more frequently performed than in the United 
States, and peril ajjs none where fewer accidents from the 
ojje.ration have occurred, of these few, I beg leave to 
state, that all the aneurisms produced by bleeding, which 
I have seen, have been in cases where the lancet was 
used."' I have since however met with an exception to 
this statement. I have seen the brachial artery opened 
by a spring-lancet, but it was by an old barber, half 
blind, and very clumsy. 

" The manner of using the spring-lancet differs in 
nothing from the operation with the common lancet, ex- 
cepting that the surgeon must place the instrument in 
such a situation, o\er the vein, that when the spring is 
touched, the orifice into the vein will have a proper size 
and direction. Dexterity in this is very readily and 
speedily acquired. In point of facility in its use it has 
a great advantage over the lancet. 

•• Among the advantages of the spring-lancet economy 
is not the least. A country practitioner who is constantly 
employing the English lancets, and who is particular in 
nsins ooue but the best, must ueces«arilv consume half 



358 ELEMENTS OF SURGERY. 

the emolument derived from the operation, in the pur- 
chase of his instruments. One spring-lancet, with anoc 
ansionsl new Made, will serve him all his life." 

ARTERIOTOMY. 

Arteriotomy is commonly performed by puncturing the 
trunk or branches of the temporal artery. The vessel in 
geueral lies so near the surface that a lancet may easily 
be inserted into it — after enough blood is evacuated the 
bleeding is readily arrested by applying a compress and 
bandage. When difficulty is experienced in stop- 
ping the bleeding, it has been found useful to divide the 
artery entirely ; which facilitates, if Dr. Jones's experi- 
ments be not fallacious, the natural process by which the 
bleeding is stopped. 

CUPPING. 

Cupping consists in extracting blood by an exhaust- 
ed receiver from punctures made in the skin. It is 
performed by means of a scarificator, and a small bell 
glass, or tin cup, the mouth of which is more contract- 
ed than the bottom. The scarificator is an instrument 
containing from sixteen to twenty small lancets, which 
start out when a spring is touched, and make the neces- 
sary punctures of a proper depth ; the depth being re- 
gulated by means of a screw. The small cutaneous 
vessels only are divided in this operation, and it is ne- 
cessary to promote the bleeding by applying the cups, 
exhausted of air, or rather filled with air greatly rarified, 
over the punctures. This part of the operation is effect- 
ed by moistening the skin with warm water, and by 
beating the air in the cup by the flame of a small lamp 
(which requires much dexterity and practice, but is cer- 
tainly the best method) or by a piece of paper, or tow 



ELEMENTS OF SURGEIlY. 



35*9 



dipped in spirits of wine and inflamed, which is thrown 
into the cup immediately before its application. In this 
manner a powerful suction is made and the blood flows 
into the cup : when the cups are moderately full they 
may be emptied and reapplied. 

It is best to apply the cups before making the scarifi- 
cations, in order to render the vessels turgid, and they 
Meed more freely after this manoeuvre. 

LEECHING. 

Within a few years leeches have been found in great 
abundance, and have been introduced extensively into 
practice in this city, and in other parts of the United 
States. Bleeding by leeches occasions less irritation 
than cupping, and is preferable in a great number of 
cases. The mode of using them which succeeds best in 
the hands of those whose business it is to apply them, 
consists in confining a number of the leeches in an in- 
verted glass or cup, over the part from which the blood 
is to be drawn, and this part is previously smeared with 
blood drawn from the operators finger by a lancet or pin, 
from time to time the glass is taken up to ascertain when 
the requisite number have adhered, and when this is ef- 
fected the glass is removed, and the leeches after filling 
themselves with blood successively drop oft'. The leech- 
ers in this town generally moisten their leeches, with 
warm water to enliven them. 



S60 ELEMENTS OF SURGEKY. 



CHAPTER XLIX, 



Of Vlters. 

An ulcer is a solution of continuity in a soft part, dis- 
charging pus. 

Ulcers arise from various accidental injuries which 
are succeeded by inflammation and suppuration, as from 
wounds, bruises, burns, &c, They also occur in all cases 
where a part of the body has been destroyed by morti- 
fication, and they are the result of certain morbid ac- 
tions attended with local inflammation, as scrofula, sy- 
philis, &c» 

The nature of the ulcerative process has been already 
cursorily explained in the chapter on inflammation, and 
a very short account of the manner in which injured 
parts are restored, has been offered in the commencement 
of the present work — it will not, however, be unpro- 
fitable to enlarge a little on the latter subject, because 
the cure of ulcers must be attempted under great disadvan- 
tages, by one who is but partially acquainted with those 
operations of nature which it is his business to facilitate. 

When a part of the body is wounded, blood is poured 
out, and this blood sometimes becomes the bond of 
union ; at other times this effect does not happen, but in- 
flammation arises, and coagulating lymph is secreted and 
poured out, and this forms the uniting medium. But 
the circumstances of an ulcer differ very materially from 
those of a wound. The absorbent vessels have removed 
in cases of ulcer a portion of the original flesh, and a 
vacuity more or less considerable is occasioned by this 
loss of substance. The whole nature of the part is 



ELEMENTS OF SURGERY. 361 

changed — it is no longer skin, or muscle, but a secret- 
ing surface, constantly inflamed, and pouring out a fluid. 

A wound, however, may very readily be converted 
into an ulcer, and the change takes place in the follow- 
ing manner. In every wound there is a solution of con- 
tinuity in a soft part ; blood is poured out and generally 
fills the cavity of the wound ; the bleeding having ceased, 
this blood coagulates. Inflammation succeeds, and the 
part becomes red, tense, swollen, hot, and painful. The 
coagulated blood putrefies, and dissolves, emitting an 
oflensivc odour ; the first discharge therefore from the 
wound is putrid blood ; but soon after a secretion of se- 
rum takes place, and this mixes with the putrid blood 
and flows out together with it. The serous thin discharge 
gradually becomes changed in colour and consistence, 
approaching more and more in its appearance to pus, 
and generally in four or live days the inflammation hav- 
ing abated, pure pus is discharged. In order for the 
restoration of suppurating wounds something more is re- 
quisite than what takes place in those which are healed 
by the first intention. " For there is always a consider- 
able gap, by the opposite parts retracting from each other. 
This gap is, of course, greater in wounds with loss of 
substance, than in others ; but it occurs in all. In order 
to fill up this vacancy, a growth of new flesh is necessa- 
ry, and accordingly there sprouts up a new kind of sub- 
stance, which is named granulations, from all the in- 
flamed surfaces. 

" This substance is of a florid red colour, it arises 
with small irregular round points, something like little 
grains (hence the name) or rather resembling the head of 
a cauliflower. 

" The surfaces of the granulations are moist by their 
constantly secreting pus ; and they are so tender that 
they bleed if touched a little roughly. This delicate pro 
duction springs up in a very irregular manner from the 
Voi II 3 A 



862 ELEMENTS OF SURGERY. 

whole suppurating surfaces ; in some parts it sprouts up 
exuberantly, sending forth pyramids and columns; while 
in others it goes on very slowly. 

" In general the principal growth is from the bottom 
and deeper parts of the wound, very little arising from 
the superficial. 

" When two granulations come in contact, they ad- 
here and grow together. In this manner they increase 
and unite, until the whole cavity of the wound is filled 
with them as high as the skin. 

" This new iiesh is of the same nature and appearance, 
from whatever part of the body it springs ; even that 
which arises from bones, differs in no respect from that 
which grows from the softest parts. When granulations 
are cut, they appear a uniform mass without fibres run- 
ning in any particular direction. They seem principally 
composed of blood-vessels ; and as the blood circulating 
in them is nearly in contact with the air, it acquires the 
florid red colour, which good blood always receives 
when in that situation. There are a great many lym- 
phatics in granulations, which is proved by salivations 
having been induced by dressing sores with mercurial 
applications. Nerves likewise enter into their composi- 
tion, as is evident from their sensibility ; and besides this 
congeries of vessels and nerves there is probably a con 
necting substance uniting all these parts together. 

" Such is the nature of the new flesh which arises to 
fill up a suppurating cavity, and to unite the solution of 
continuity. But this substance does not begin to spring 
up for the first three or four days. During that period 
the fever is high, there is a great deal of redness, hard- 
ness, and tension, in all the parts contiguous to the 
wound, and the pain and heat are considerable. 

" These symptoms gradually diminish. At length all 
pain and tension disappear, and the redness is confined 
to the surface of the sore, and less than a quarter of an 



ELEMENTS OF SURGERY. 363 

mch around it. The discharge, likewise, also alters 
materially. It is at first of a thin consistence, of a se- 
rous colour and offensive smell : and by degrees it be- 
comes thick and viscid, of a yellowish or white colour, 
and nearly inodorous." (Moore.) 

The parts are now in the condition of a healthy or 
healing ulcer, and resemble those ulcers which arise 
from the separation of mortified flesh, and all such as are 
attended with no local err general morbid affection, and 
in which the parts have sufficient strength to effect the 
process of restoration. 

In a simple or healthy ulcer as the granulations arise 
the discharge is diminished in quantity, and becomes 
thicker in consistence ; at length the deficiency of sub- 
stance is repaired, and there remains no longer a cavity, 
but the granulations are on a level with the surrounding 
skin, or elevated somewhat above it. The process of 
cicatrization or the formation of skin next commences. 

" The formation of the cicatrix begins from the edges 
of the old skin. The redness which existed during the 
inflamed state abating, the swelling subsiding, and the 
edges of the sore uniting with the rising granulations. 
The margin then acquires a bluish white or pearly co- 
lour, which gradually extends itself to the centre, till the 
whole sore is covered with new skin. It sometimes hap- 
pens in broad sores, that cicatrization takes place not 
only from the circumference, but likewise from one or 
two points in the centre ; these appear like islands in 
the midst of a sea of granulations ; they are of the same 
colour as the healing margin ; and they become larger 
by extending in every direction. In consequence of ci- 
catrization going on from different central parts, it hap- 
pens not unfrequently during the progress of healing, 
that one broad sore is divided iuto two or three smaller 
ones ; and when this happens, the cure must go on 
faster. There is always more or less of a cuticular co- 



JG1 ELEMENTS OF SURGERY. 

vering upon the cicatrix, which being constantly mois- 
tened by the discharge from the granulations, is soft and 
pulpy, and occasions that whitish colour observable on 
the edges of healing sores. I have sometimes removed 
this cuticular substance, and have observed underneath 
the real new skin, which seems a very fine membrane of 
a red colour, the granulations shining through it. 

" When a suppurative sore is nearly healed, if it is 
not kept moist by some application, a. scab is apt to form 
in the same manner as in those wounds which are healed 
by the first intention. This crust consists of pus dried 
by the evaporation of the watery parts ; the new skin 
forms under it, and it soon after falls off. 

" From the surface of the cicatrix there is no secre- 
tion; there are only the perspirable vessels. AVhile it 
is forming it is kept moist by the discharge from the un- 
covered granulations ; but when completely formed, the 
cicatrix is as dry as any other skin. 

" It appears that the new skin at first cannot form a 
good cuticle and rete-mucosum, for there is always a 
succession of scales falling off for sometime ; at last this 
ceases, and the new skin is covered with a good cuticle 
and rete-mucosum, like other parts. The cicatrix 
changes successively from a reddish colour to a brown; 
and lastly it becomes whiter, and of a more shining ap- 
pearance than the original skin. This is a curious cir- 
cumstance and merits some attention. 

" The cutis, as every anatomist knows, is not a smooth 
polished membrane, but is full of eminences, which are 
named papillae. These, in some parts of the body, run 
in waving rows, and form in others irregular lozenges 
and triangles. The rete-mucosum and cuticle which lie 
immediately over the cutis, are marked with furrows 
analogous to the eminences of the cutis. The cuticle is 
of a light colour and semi-transparent. The rete-muco- 
sum, is white, yellowish, brown, or black, in men of 



ELEMENTS OF SURGERY. 365 

these various colours. And the cutis is extremely vascu- 
lar ; the blood contained in these vessels shines through, 
and gives the florid fleshy tint to the body. 

"The colour of the skin, then depends partly upon 
the rete-mucosum, and partly upon the blood which cir- 
culates in the cutis. In white men the cuticle and rete- 
mucosum, which cover cicatrices, appear similar to that 
which covers other parts ; but there is a great difference 
in the quantity of blood, which circulates in the old and 
new skin. "For the new is far less vascular than the 
old ; or, at least, the greater number of its vessels are of 
a much smaller diameter, and admit a lesser quantity of 
red globules of the blood. It happens in consequence 
of this that the cicatrices are of a whiter colour than the 
original skin. In negroes the reverse takes place, their 
scars being generally blacker than other parts, owing to 
a darker rete-mucosum forming in them upon scars, than 
upon the old skin. 

" Besides the difference of colour, a cicatrix has a 
glossy, shining look, which the skin does not possess : 
this is owing to the scar being a smooth polished mem- 
brane without hair, or any of those papilla;, which arc 
upon the cutis ; both the papillae and hair are parts which 
are formed in the first organization of the body, and are 
never afterwards produced. 

u As scars are less vascular than the old skin, it is 
probable that they have fewer nerves; for blood-vessels 
and nerves are generally in proportion to one another. 
But as nerves can hardly ever be traced to the surface of 
the body, we can only judge of their number there, by 
the degree of sensibility ; and this is considerably weak- 
er in cicatrices thau in old skin. This indeed might na- 
turally be expected, for scars have no papiiL , which 
are supposed to be the principal seat of the sense of feel- 
ing in the skin. 



366 ELEMENTS OF SURGERY. 

" It is observed that scars are generally far less move- 
able than the original skin : the latter being commonly 
attached by a loose cellular membrane to the deep seated 
parts ; whereas the scar forms itself immediately upon 
the granulations, and is so intimately connected, as to 
make the same substance with them. This is the reason, 
likewise, that although a scar is at first exactly level 
with the skin, yet after a certain period, it is often de- 
pressed. For during iho healing of a sore, particularly 
if the discharge is great, the fat and neighbouring flesh 
are considerably wasted by absorption. But when the 
whole is healed, the internal parts recover their bulk, 
and the fat is regenerated. The skin being attached 
loosely, readily yields and accommodates itself to this 
increase ; whereas the cicatrix adhering closely, and be- 
ing as it were tacked down to the parts upon which it is 
formed, appears, depressed. 

" It sometimes happens that a cicatrix instead of being 
depressed, rather projects above the skin owing to the 
exuberancy of the granulations upon which it is formed ; 
and very often the scar has an irregular, unseemly 
appearance, from the granulations rising to unequal 
heights." 

With respect to the nature of the new-formed parts 
various opinions have existed. It is certain, however, 
that in some cases they resemble somewhat the origi- 
nal flesh, the deficiency in which they are intended to 
8u Pply> an d m other instances the parts newly formed 
differ very essentially from it. 

Mr. Moore observes that « in some cases the body is 
unable to produce any new substance to supply the place 
of that which was lost, and nothing more is attempted 
than simply to throw a cicatrix over the sore. In other 
cases a new substance is formed which fills up the va- 
cuity, but is incapable of performing the office of the old, 



ELEMENTS OF SURGERY. 367 

and lastly it sometimes happens that a new substance is 
produced similar to the old and fit for all its offices." 

The quantity of new parts formed is not always equal 
to the parts which have been lost, and in the healing of 
certain ulcers, a great difference is observed between the 
size of the original sore and that of the cicatrix, which re- 
mains after it has healed, owing to the power which the 
granulations have of contracting. This is most evident in 
ulcers seated in parts where, the skin is loose : in such 
cases plaits or folds are often formed in the skin in con- 
sequence of the contraction of the granulations. The 
healing of a sore is much expedited by this process. 

This long account of the healing of ulcers I consider 
by no means unimportant, as it will preclude repetitions 
in the remaining pages. 

The simple or healing ulcer then it appears needs 
no surgical treatment, but requires only rest to enable the 
parts to restore themselves ; cleanliness is however ne- 
cessary, because filth like all other irritating matters will 
occasion inflammation and thereby retard the cure. 

Notwithstanding the tendency of the healthy ulcer to 
cicatrize, it is a fact that trifling circumstances influence 
very materially the rapidity of the cure, and therefore 
Mr. Home very properly advises the dressings to be such 
as best agree with the granulations, and with the sur- 
rounding skin. In general dry lint is the best applica- 
tion, as it absorbs and retains the matter from the sore, 
and serves as a soft covering for the granulations ; over 
this lint it is proper to apply a pledgit spread with sim- 
ple cerate, to prevent the evaporation and drying of the 
matter, and to facilitate consequently the removal of the 
dressings. 

In many instances moderate pressure promotes the 
healing of an ulcer, and in others it retards it : some ul- 
cers heal most readily when dressed with simple cerate. 



368 ELEMENTS OF SURGERY. 

and others when allowed to scab and dry. Mr. Home 
does not ascribe these variations to disease, but to con 
stitutional causes, for the ulcers heal as soon as the par- 
ticular things which disagree with them are discontinued. 
It is proper therefore to ascertain from patients having 
ulcers, what particular applications have formerly agreed 
best with their sores, because both in healthy and dis- 
eased ulcers it will be proper to avoid those dressings 
which have provwl injurions. 

Various circumstances take place to interrupt the heal- 
ing of ulcers, and accordingly we find many of them very 
obstinate and difficult of cure. It would be an endless 
labour to describe all these circumstances. I shall there- 
fore detail the appearances and treatment of those ulcers 
most frequently met with. 

Ulcers are more frequently situated in the legs than 
in any other part, and are more obstinate from circum- 
stances which it is not necessary to explain. Mr. Home 
jn his excellent treatise on the present subject, has de- 
scribed the various ulcers which are met with under six 
different divisions. 

1. Ulcers in parts which have sufficient strength to 
carry on the actions necessary for their recovery. 

2. Ulcers in parts that are too weak for that purpose. 

3. Ulcers in parts whose actions are too violent to 
form healthy granulations whether this arises from the 
state of the parts or of the constitution. 

4. Ulcers in parts whose actions are too indolent, 
whether this arises from the state of the parts or of the 
constitution. 

5. Ulcers in parts which have acquired some specific 
action either from a diseased state of the parts or of the 
constitution. 

6. Ulcers in parts which are prevented from healing 
by a varicose state of the superficial veins of the uppei 
part of the limb. 



ELEMENTS OF SURGERY. 369 

Dr. Physick in order to describe the usual appear- 
ances of old ulcers, classes them under the following 
heads, some of which are noticed and some omitted by 
Mr. Home, viz. 

1. The inflamed ulcer. 

2. The fungous ulcer. 

3. Ulcers seated in cedematous limbs. 

4. The sloughing ulcer. 

5. The indolent ulcer. 

6. Ulcers attended with carious bone. 
7- Ulcers attended with varicose veins. 

8. Ulcers attended by specific diseased actions. I 
shall adopt the latter arrangement in the following 
pages. 

The appearance of a healthy ulcer such as Mr. Home 
describes in his first division, has already been mentioned. 
The granulations in such an ulcer are small, firm, florid, 
and somewhat pointed at the top. They secrete pus of a 
light yellow or whitish colour, of a thick consistence, 
separating readily from the surface of the sore. When 
the granulations arrive at the level of the surrounding 
skin, cicatrization takes place in the manner already de- 
scribed. 

But if from accidental irritation, or from constitutional 
affection, inflammation runs so high as to interrupt the 
process of healing, the condition of the ulcer is materially 
changed. 



vol. ii. 3 b 



3^0 ELEMENTS OF SURGERY. 

CHAPTER L. 

Of Inflamed Ulcers. 

It might be supposed by persons unacquainted with 
the subject that no difficulty could exist in distinguishing 
from the appearance, an inflamed ulcer from any other, 
but the fact is otherwise, and although the circumstances 
of the cases considered in connection, sufficiently discri- 
minate the inflamed ulcer, yet except in strongly marked 
cases, the mere aspect of the sore is not sufficient to ena- 
ble the surgeon to decide whether an ulcer is inflamed. 

An inflamed ulcer in general puts on the following ap- 
pearances. 

The surrounding parts are red, swelled, and very sen- 
sible to the touch ; the blood pressed out of them with a 
finger quickly returns, and the red colour with it ; the 
margin of the sore is ragged, the skin terminating in a 
sharp elevated edge around it ; the bottom of the ulcer 
is made up of concavities and no distinct appearance of 
granulations is seen — a whitish spongy substance exist- 
ing in their room formed of coagulating lymph. The dis- 
charge from an inflamed ulcer is thin and serous, and by 
no means resembles healthy pus. The surface of the 
sore is acutely sensible, and often bleeds when touched 
or irritated. 

The pain attending an inflamed ulcer is in some cases 
very great ; in general it is not constant, but comes on 
usually in the evening, and continues several hours, at- 
tended in some cases with spasms of the limb. 

The ulcers on the legs of sailors and intemperate per- 
sons generally exhibit, on their admission into a hospital, 
the symptoms and appearances just described, and that 
such ulcers are inflamed there can be no doubt. 



ELEMENTS OF SURGERY. 371 

When, however, these marks are not present, the his- 
tory of the case and the effects of medicines upon the 
sore enable us to decide, and it is in general a good rule 
to consider all doubtful cases as inflamed, because the 
remedies indicated will do no mischief in any case in 
which this point is doubtful, and their ill success in case 
of error will be speedily apparent without any serious or 
permanent injury. 

The treatment of an inflamed ulcer consists in the use 
of the common remedies for inflammation — Rest in a 
horizontal posture — a low diet — purging and occasional- 
ly blood-letting. The best local application is a soft 
bread and milk, or linseed poultice. When by these mea- 
sures the inflammation is lessened and the sore assumes 
the appearance of a healthy ulcer, it is to be treated as 
has been already directed. 



372 



ELEMENTS OF SURGERY. 



CHAPTER LI. 

The Fungous Ulcer. 

Instead of the healthy appearance of florid pointed 
granulations of a firm texture, the fungus ulcer is covered 
with large round granulations rising above the level of 
the surrounding parts ; they are less compact in texture, 
and appear somewhat transparent; they have no disposi- 
tion to cicatrize. In some cases the sensibility of the 
granulations is greater than in healthy sores, and bleed- 
ing takes place from every accidental irritation — at other 
times they are not very sensible and less vascular than 
healthy granulations. 

The treatment of fungous ulcers is to be commenced 
by pressure made with a bandage and roller, or by dress- 
ing in the manner recommended by Mr. Baynton for the 
cure of old ulcers, which will be described when the 
treatment of indolent ulcers is considered. If the pres- 
sure should not prove successful, escharotic applications 
are to be used ; the red precipitate answers in many cases 
very well, but should this fail lunar caustic is to be ap- 
plied, and the granulations around the edges of the sore 
are to be destroyed by this application, after which the 
ulcer may be dressed twice a day with simple cerate and 
a roller of muslin. Should the ulcer be of small size the 
whole surface may be touched with caustic at once. 

It is worthy of remark, however, that in some cases an 
ulcer will shoot up fungous granulations after the appli- 
cation of lunar caustic or red precipitate, and this disposi- 
tion will be effectually checked by an application of blue 
vitriol. The use of burnt alum is in many cases extremely 
serviceable in repressing fungous granulations. Various 



ELEMENTS OF SUTtGERY. 3^3 

astringent lotions are also useful ; a decoction of oak 
galls ; solutions of white vitriol, and other metallic salts 
have been found beneficial. It is my custom therefore 
always to vary the escharotic medicines in such cases, and 
sometimes the ulcer heals under the use of one which in 
other cases has no effect. 

The great extent to which fungous granulations pro- 
ceed in some cases is truly surprising. Cancerous ul- 
cers sometimes shoot out a fungus, which grows so ra- 
pidly that its increase in volume is almost visible. It 
is exceedingly difficult in such cases to repress the fun- 
gus ; the older surgeons employed wooden cups which 
were bound fast upon the ulcer, and by means of these 
they compressed the granulations. Stimulating applica- 
tions aggravate the complaint, and are therefore inad- 
missible ; moderate pressure ought to be applied, and 
antiphlogistic measures should be employed to mitigate 
the pain and inflammation which attend. 



374) ELEMENTS OP SUIiGERY. 

CHAPTER LII. 

Of Ulcers in (Edematous Limbs. 

(Edema signifies au extravasation of water into the 
cells of the cellular texture, and is a local anasarca, dif- 
fering from general dropsy only in extent. It depends 
therefore frequently upon general or constitutional causes, 
but also very often upon local circumstances, and pro- 
ceeds from fractures, sprains, and bruises. Interruptions 
to the circulation of a part in some cases produce this 
effect, and (Edematous swellings result from the pressure 
of a tumour upon the principal vessels of a limb. In the 
latter months of preguancy cedematous legs are very 
common. 

An cedematous limb is usually cold, swollen, and of a 
pale colour. It retains the mark or pit made by the pres- 
sure of a finger. An ulcer seated in such a limb is ge- 
nerally painful and somewhat inflamed. The granula- 
tions have not a healthy appearance, but are purple, and 
in spots appear gangrenous or sloughy. Great pain is 
sometimes felt, and the ulcer remains stationary or spreads 
in extent. 

Ulcers in cedematous limbs very frequently are attend- 
ed by so much fever that blood-letting is indicated, and 
repeated purges are often necessary. In many instances, 
however, the patient's strength is so much reduced that 
these remedies cannot be used, and in such cases Dr. 
Physick's plan of elevating the feet of the bedstead has 
a very happy effect in diminishing the bulk of the limb, 
and in abating the inflammation of the ulcer. In addi- 
tion to this, gentle pressure is to be made by means of a 
roller of muslin or a laced stocking extending from the 



.. - J OF SURGERY. 3^5 

foot to the knee, and the ulcer is to be dressed with 
strips of adhesive plaster, its edges being approximated 
as much as possible. 

Under this treatment the ulcer generally heals, but the 
bandage or laced stocking should be worn for a consi- 
derable time, to prevent its recurrence. 

It is the custom with many practitioners to recommenji 
exercise to patients with ulcers in cedematous legs ; this 
treatment I believe to be very injurious, and although 
cases are brought forward to attest its efficacy, it is ex- 
tremely probable that these cures would have taken place 
without the exercise, and in a much shorter space of 
time ; in proof of this I would remark that when an cede- 
matous limb is in a depending posture during the day, it 
is found greatly swelled at night, and of course the cells of 
the cellular texture are distended, and the vessels of the 
ulcer and adjacent parts are stretched and irritated — a 
condition surely unfavourable for the healing of the sore. 



376 ELEMENTS U* SUKUEltY. 

CHAPTER LIIL 

The Sloughing Ulcer. 

In consequence of deficiency in the strength of the 
constitution or part affected, the granulations of an ulcer 
very frequently mortify, and sloughs fall off from various 
parts of the ulcer, and sometimes from its whole surface ; 
in some cases this sloughing takes place after the cuticle 
is formed, the new skin becoming purple, livid, and 
black. 

The sloughing of an ulcer sometimes depends on local 
causes, and it has happened that an ulcer on one leg of a 
patient has healed up whilst the sloughing was going on 
in a sore on the other leg. That general or constitutional 
causes often occasion ulcers to slough there is no doubt, 
for change in diet or air frequently produce sloughing in 
ulcers which have been healing. In general pain and 
fever attend a sloughing ulcer. 

Analogous to this species of ulcer is that in which the 
process of ulceration suddenly takes place, after a sore 
has been apparently healing. This is owing in Mr. 
Home's opinion, to the parts being too weak to carry on 
the actions necessary for their recovery : such ulcers Mr. 
Home remarks do not readily form skin and "in a still 
more weakened state of the parts the granulations after 
having gone on favourably for several days shall all at 
once give way and be absorbed into the constitution, leav- 
ing the ulcer as broad and as deep as it was before, the 
granulations not being strong enough to preserve them- 
selves from decay. 

" Ulcers may from the beginning exhibit these appear- 
ances of want of strength in the newly formed parts, or 



ELEMENTS OF SURGERY. %jy 

they may at first go on for a few days in every respect 
like those in healthy parts, but become unable to do so 
beyond that period, and the granulations begin then to 
shew sigus of weakness ; for granulations of the most 
healthy kind if they are not skinned over in a certain 
time appear to lose their original strength and fall into a 
weak state." 

In the treatment of the sloughing ulcer and of such ul- 
cers as have just been described, tonics are requisite. The 
state of the system generally indicates them. Bark, wine, 
porter, and a generous diet are to be directed, and opium 
must be given to relieve pain. 

The best local applications are those of a moderately 
stimulating kind. It has been usual to apply bark in 
powder to the sore, and lapis calaminaris, prepared chalk, 
plaster of paris, &c. A soft carrot poultice is to the pa- 
tient pleasanter, and I believe in general answers better 
than any of these remedies. It is prepared by boiling 
scraped carrots in milk. Sometimes advantage is deriv- 
ed from washing the ulcer with diluted laudanum, or an 
infusion of oak galls. Mr. Home recommends spirit of 
wine and a decoction of poppies in equal proportions. He 
says " they must not be applied hot ; they often soothe 
the sensations of the parts and lessen their actions. Where 
the granulations appear to be disposed to run into mortifi- 
cation, this application is sometimes the means of pre- 
venting it." 

The sloughs having separated, the ulceT is to be treat- 
ed as a simple healthy ulcer, but the state of the system 
in this as in every other form of the disease, must be 
strictly attended to, and general remedies adapted to it 
must be administered. 

VOL. II. 3 c 



378 ELEMENTS OF SURGERY. 

CHAPTER LIV. 

Of Indolent Ulcers. 

Chronic ulcers generally become indolent, and from 
the frequent interruptions to the curative operations of 
nature, incapable of forming healthy granulations. In- 
dolent ulcers are generally characterized by appearances 
very unlike those of a healthy ulcer. "The edges of the 
surrounding skin are thick, prominent, smooth, and round- 
ed. The granulations are smooth and glossy on the surface. 
The pus is imperfectly formed, but not thin and watery ; 
it consists of pus and coagulating lymph mixed. The 
lymph is made up of flakes, and is with difficulty sepa- 
rated from the surface of the granulations, so that when 
the ulcer is wiped clean the coagulating lymph adheres in 
several places giving a white appearance to these parts of 
the ulcer. The bottom of the ulcer is commonly all of 
the same level or nearly so. The general aspect gives 
the idea of a portion of the skin and parts underneath 
having been for some time removed, and the exposed 
surface not having commenced any new action to fill up 
the cavity. 

" These appearances are only met with in the truly 
indolent ulcers, in which the symptoms are the most 
strongly marlfed ;" in others of this species the appear- 
ances very much resemble those that belong to the in- 
flamed ulcer, and indeed we are sometimes only able to 
ascertain the difference by the effects of our remedies. It 
is to be recollected, however, that many indolent ulcers 
become at times inflamed, and when the temporary in- 
flammation subsides revert to their old condition. 

The treatment of indolent ulcers is a subject of ac- 



ELEMENTS OF SURGERY. 379 

knowledged and great difficulty ; it is also one of great 
importance, because by far the greater proportion of ul 
cers on the legs are of this kind, and the continuance of 
any other ulcers almost invariably produces these. It is 
this form of ulcer which fills the wards of hospitals and 
poor-houses, and which incapacitates from duty large 
numbers of soldiers and sailors. 

In the treatment of indolent ulcers, Mr. Home observes 
our object should be " not simply to produce a cure, but 
to render that cure as permanent as possible. This is 
only to be done by changing the disposition of the granu- 
lations, and rendering them strong enough to stand their 
ground after the ulcer is completely filled up." 

In cases where inflammation supervenes upon an indo- 
lent ulcer the usual remedies for inflammation are to be 
employed, and when the inflammatory symptoms have 
subsided, Dr. Physick's practice has been " to remove 
completely the callous edges and the whole surface of 
the ulcer, and thereby to change its nature entirely by 
reducing it to the condition of a sore from accident." The 
success of this practice has for many years been proved 
at the Pennsylvania Hospital, by the numerous and 
speedy cures of chronic ulcers of the legs. The modes 
of effecting the object are by means of the knife or caus- 
tic ; in general the latter is preferable. The edges of the 
sore will commonly be found most readily removed by 
rubbing a piece of caustic vegetable alkali fifteen minutes 
upon them, and care should be taken completely to ac- 
complish this end. After the sloughs separate the gra- 
nulations which arise will probably require very repeated 
applications of caustic, and the lunar caustic is then to be 
employed. It should be applied daily to the sore, but 
not in sufficient quantity to produce much sloughing. 
When cuticle begins to form, the caustic must be spa- 
ringly used, but still it must be used, and applied chief- 
ly to the middle of the ulcer. 



ggQ ELEMENTS OF SURGERY. 

la order to stimulate the granulations of indolent ul- 
cers, an almost endless variety of applications have 
been recommended; all the escharotic medicines — red 
precipitate — corrosive sublimate, green, blue, and white 
v it r iol — nitric, muriatic, and sulphuric acid — caustic, and 
mild potash — carbonate of soda — alkohol, and numerous 
tinctures — gastric liquor — rhubarb — powdered galls — 
Peruvian bark, and a thousand other stimulating articles, 
all of which have in some cases proved beneficial, and in 
indolent ulcers a change of practice should be adopted 
whenever the sore becomes stationary, or worse. 

I have applied with great advantage, powdered can- 
tharides to certain indolent ulcers of the leg. The cases 
in which they have proved most beneficial are those in 
which there is a cluster of small ulcers, which have re- 
fused to yield to the common treatment. One remark I 
wish to make in this place with respect to local applica- 
tions to indolent ulcers, which is, to vary them whenever 
they cease to produce a good effect. 

I shall next detail Mr. Baynton's method of treating 
chronic ulcers, which has been adopted by almost every 
modern surgeon, and which ought to be used in conjunc- 
tion with the remedies which have been recommended. 
I would premise, however, that Mr. Baynton accom- 
plished his cures without pain or confinement, advantages 
obtained by few other surgeons, and the practice of al- 
lowing patients with ulcers to walk about is so generally 
injurious and so very rarely beneficial, that a prohibition 
of exercise ought in my opinion almost universally to be 
made. 

" The parts should be first cleared of the hair, some- 
times found in considerable quantities upon the legs, by 
means of a razor, that none of the discharges, by being 
retained, may become acrid, and inflame the skin, and 
that the dressings may be removed with ease at each 



ELEMENTS OF SURGERY. 38 £ 

time of their renewal, which in some cases, where the 
discharges are very profuse, and the ulcers very irrita- 
ble, may, perhaps, be necessary twice in the twenty-four 
hours, but which I have, in every instance, been only 
under the necessity of performing once in that space of 
time. 

" The plaster should be prepared by slowly melting, 
in an iron ladle, a sufficient quantity of litharge plaster, 
or diachylon, which, if too brittle, when cold, to adhere, 
may be rendered adhesive by melting half a drachm of 
resin with every ounce of the plaster : when melted it 
should be stirred till it begins to cool, and then spread 
thinly upon slips of smooth porous calico, of a conve- 
nient length and breadth, by sweeping it quickly from 
the end, held by the left hand of the person who spreads 
it, to the other, held firmly by another person, with the 
common elastic spatula used by apothecaries ; the un- 
even edges must be taken off, and the pieces cut into 
slips, about two inches in breadth, and of a length that 
will, after being passed round the limb, leave an end of 
about four or five inches. The middle of the piece so 
prepared, is to be applied to the sound part of the limb, 
opposite to the inferior part of the ulcer, so that the lower 
edge of the plaster may be placed about an inch below 
the lower edge of the sore, and the ends drawn over the 
ulcer with as much gradual extension as the patient can 
well bear ; other slips are to be secured in the same way, 
each above and in contact with the other, until the whole 
surface of the sore and the limb are completely covered, 
at least one inch below and two or three above the dis- 
eased part. 

" The whole of the leg should then be equally de- 
fended with pieces of soft calico, three or four times dou- 
bled, and a bandage of the same, about three inches in 
breadth, and four or live yards in length, or rather as 



38& ELEMENTS OF SURGERY. 

much as will be sufficient to support the limb from the 
toes to the kuee, should be applied as smoothly as can be 
possibly performed by the surgeon, and with as much 
firmness as can be borne by the patient, being first pass- 
ed round the leg, at the ankle-joint, then as many times 
round the foot as will cover and support every part of it, 
except the toes, and afterwards up the limb till it reaches 
the knee, observing that each turn of the bandage should 
have its lower edge so placed as to be about an inch 
above the lower edge of the fold next below. 

"If the parts be much inflamed, or the discharge very 
profuse, they should be well moistened, and kept cool 
with cold spring- water poured upon them as often as 
the heat may indicate to be necessary, or, perhaps, at 
least, once every hour. The patient may take what ex- 
ercise he pleases, and it will be always found, that an 
alleviation of his pain and the promotion of his cure, will 
follow as its consequence, though, under other modes of 
treating the disease, it aggravates the pain and prevents 
the cure. 

"These means, when it can be made convenient, 
should be applied soon after rising in the morning, as 
the legs of persons affected with this disease are then 
found more free from tumefaction, and the advantages 
will be greater than when they are applied to limbs in a 
swollen state. But at whatever time the applications be 
made, or in whatever condition the parts be found, I be- 
lieve it will always happen, that cures may be obtained 
by these means alone, except in one species of the dis- 
ease, which seldom occurs. The first application will 
sometimes occasion pain, which however, subsides in a 
short time, and is felt less sensibly at each succeeding 
dressing. The force with which the ends are drawn 
over the limb, must then be gradually increased, and 
when the parts are restored to their natural state of ease 



ELEMENTS OF SURGERY. 383 

and sensibility, which will soon happen, as much may 
be applied as the calico will bear, or the surgeons can 
exert ; especially if the limb be in that enlarged and in- 
compressible state which has been denominated the scor- 
butic, or if the edges of the wound be widely separated 
from each other." (Baynton.) 

Mr. Baynton's direction to cover the ulcer completely 
with strips of adhesive plaster, is I think very injudicious, 
because the matter will be thus confined, and a kind of 
abscess formed, the anterior parietes of which are the 
plasters. Instead of this, it is better to make use of strips 
of plaster an inch in width, in large ulcers, and narrower 
in those which are small, placed at a distance of half 
an inch, one from the other, so that a free exit may re- 
main for the pus secreted. In this manner indolent ul- 
cers heal in general more readily than under any mode 
of treatment I have ever witnessed. His remarks on ex- 
ercise I believe are altogether erroneous. 



384 ELEMENTS OF SURGERY. 

CHAPTER LV. 

The Carious Ulcer. 

Ulcers situated in the vicinity of carious or dead bone 
are prevented from healing until the exfoliation and se- 
paration of the bone are accomplished, and this in mauy 
cases is a very tedious process. 

The manner in which exfoliation takes place has been 
already explained ; the surgeon must necessarily wait 
until the bone becomes loose, after which he should with- 
out delay extract it. 

Many chronic ulcers which succeed the venereal 
disease are prevented from healing by the presence of 
dead bone ; these ulcers are not to be considered as ve- 
nereal or treated as such, because after the separation of 
the bone is effected, they readily heal. 

Carious ulcers are often fistulous, consisting of a canal 
with an indurated margin, discharging foetid sanies. 
Where a large carious ulcer exists, the fcetor is often very 
great. 

To hasten the exfoliation of carious bone is by no 
means an easy matter ; the French surgeons employ 
with this view the old and painful remedy, the actual 
cautery, and if any of the means in use can succeed, this 
is the one. I have thought it useless to recount the nu- 
merous ridiculous remedies sometimes employed with 
this view, as I believe them perfectly inert. When the 
carious bone can be removed by an operation this ought 
to be performed, in order to expedite the cure. Portions 
of the tibia can very often be cut away by means of Hey's 
saw, and the crown of a trephine. Gouges and chisels 
are also in some cases necessary. 



ELEMENTS OF SURGERY. 385 

It is in general a very bad practice to inject corroding 
liquors into sinuses leading to carious bone, because they 
act much more powerfully on the soft parts in which the 
iinus is situated than on the bone, and therefore excite 
much unnecessary inflammation. 

To attempt the healing of such sinuses before the bone 
is removed is always improper ; on the contrary, the size 
of the external aperture should be enlarged with sponge 
tent if it become very much contracted. 

The subject of caries, however, will be resumed in 
another chapter. 

The difference of time required for the separation of 
caries in different bones is very great, and if a unifor- 
mity in the exfoliation of certain bones should be found 
to exist, a very valuable table might be formed exhibit- 
ing these periods. I have known a caries of the os calcis 
in which at the end of several years the separation was 
not completed; a few months suffices in general for the 
separation of the tibia in cases where the foot and ankle 
mortify. 



vol. II. 3 D 



396 ELEMENTS OF SUItGEUV. 

CHAPTER LVI. 

Ulcers attended with Varicose Veins. 

These are a species of indolent ulcer, and resemble 
in appearance those which have been described. The 
most usual situation of ulcers in cases where the veins are 
varicose, is said by Mr. Home, to be on the inside of 
the leg, just above the ankle. They have their origin 
" from accidental causes, but when once they occur they 
are difficult of cure and almost always break out again. 
Mr. Home adds that they occur most commonly in tall 
persons. 

The branches of the saphena vein and indeed all the 
superficial veins of the leg are found in a varicose state, 
greatly distended, and the saphena itself is extremely 
large. 

" This species of ulcer is seldom very deep ; when it 
spreads it is generally along the surface ; its shape is com- 
monly oval pointing vertically. The edges of the surround- 
ing skin are commonly neither thick nor irregular, but are 
imperceptibly lost in the ulcer. The pain which it gives 
is seldom from the surface, for pressure does not increase 
it, but there is an aching uneasy sensation in that part of 
the leg. This pain is deeper seated than the surface of 
the ulcer, and very often extends up the leg in the direc- 
tion of the veins, and is increased to a very great degree 
if the limb is long kept in an erect posture. 

" It is this species of ulcer which, from its great back- 
wardness to heal, has given the idea of its being a natural 
drain from the constitution, which it was improper to dry 
up ; and the strong argument advanced in favour of this 
opinion has been, that whenever it was healed, it broke 



ELEMENTS OF SURGERY. 387 

out again, and the patient was full as easy while the ulcer 
was open, as when it was closed, if not more. This may 
at first appear extraordinary, but can be readily explain- 
ed ; since the pain, in such cases, arises more from the dis- 
tended state of the veins, than from the ulcer ; and the 
patient will naturally be led to use more exercise when 
the ulcer is healed, which will keep the veins in a more 
uneasy state. 

" This is the species of ulcer in which tight bandaging 
to the leg is particularly applicable, and rolling the 
whole limb from the toes to the knee, is found to be at- 
tended with the greatest advantage. It is to be under- 
stood that the tight bandaging is not immediately appli- 
cable to the ulcer itself, as it will appear that it is im- 
material in what way the management of the ulcer is 
conducted, and it is probable that the success of tight 
bandaging in ulcers attended with varicose veins, has led 
to the use of compression in other species of ulcers, where- 
in it has proved hurtful; not being suited to the state of 
the limb, which often is unable to bear any thing tight 
upon it. 

" Soldiers who have the slightest disposition to a va- 
ricose state of the veins, whether there is an ulcer on the 
leg or not, should have their gaiters so made as to an- 
swer the purpose of a tight bandage, which may be rea- 
dily done by having them very accurately fitted to the 
leg ; for this purpose those made of woollen cloth will an- 
swer best, as its elasticity allows it to yield to the motion 
of the muscles, and always preserves an uniform com- 
pression. 

" A laced stocking is a most useful application, and if 
it could be worn without inconvenience, probably no 
other mode of treatment would be necessary; but it too 
often happens that the patient is unable to bear the neces- 



ggg ELEMENTS OF SURGERY. 

sary degree of compression for any length of time, and 
therefore after using it for some weeks, is obliged to 
leave it off. 

" In considering the mode by which the varicose vein* 
prevent an ulcer from healing it appeared to be most rea- 
dily accounted for in the following manner. That in 
consequence of the size of the vena saphena, and its uum- 
berless convolutions, the return of the blood from the 
smaller branches is so impeded, as to retard the circula- 
tion in the smaller arteries, and to interfere with their 
action in forming healthy granulations. This observa- 
tion is, in some measure, confirmed by the following cir- 
cumstance. In cases of ulcers attended with weakness, 
on the lower part of the leg, the granulations while the 
patient lies in an horizontal position, appear florid and 
healthy ; but if he is made to stand up, and continues in 
that posture only for a few minutes, they become of a 
deep dark -red colour, and frequently bleed. This change 
can only arise from the increased resistance which the 
blood encounters in its return through the veins of the 
limb, when the body is erect. 

" An enlargement of the veins produces also another 
effect. The coats of the vessels and the valves become 
thickened, which renders valves less pliant, they do not 
occupy the whole area, and therefore are no longer of 
any use ; and from this defect the whole length of the 
column of blood in the vena saphena is in the erect posi- 
tion, pressing upon the contents of the smaller veins, so 
as to dilate them still more and more, and keep the limb 
always in a weak state. 

" Under these circumstances, it appears to be an ob- 
ject of no small importance to take off a part of the pres- 
sure of this column of blood, which would probably al- 
low the parts lower down to be in a more easy state, and 
better able to recover themselves ; it might also prevent 



ELEMENTS OF SURGERY. 389 

the veins from being still more dilated, and so far stop 
the progress of the disease in these vessels. 

" The only mode of doing this that suggested itself, 
was that of making an artificial valve, by passing a liga- 
ture round the vena saphena, as it passes over the knee 
joint, and obliterating the vein at that part. The reason 
for applying the ligature upon this particular portion of 
the vein is, that just at that part the branches from the 
different parts of the leg unite and form a common trunk, 
and as it is the preternatural enlargement of some, or all 
these branches, which constitutes the principal part of the 
disease, the most effectual mode of taking off the weight 
of the column of blood contained in the common trunk 
will be by obliterating it, as near as possible to the ter- 
mination of those branches into it." (Home.) 

Mr. Home accordingly performed the operation of ty- 
ing up the saphena with a view to heal ulcers on the 
leg, in a variety of instances with complete success, and 
is the author of the practice ; for although Mr. Hunter 
had previously tied up some veins in the leg, and also 
several very old surgeons, yet it was with very different 
views, and without any reference to this object. Dr. 
Physick has practised Mr. Home's operation in a num- 
ber of cases, with various success ; in some instances the 
ulcers have healed very rapidly, in others no benefit has 
apparently resulted. I have myself several times per- 
formed it, and always with advantage. In the hands of 
other surgeons it has proved in many cases beneficial, 
but in some instances the operation has been followed 
by death from tetanus, in others by inflammation of the 
internal coat of the vein — accidents which in America 
I believe have never succeeded this operation, and 
therefore in those cases where ulcers of the leg are evi- 
dently kept from healing by a varicose state of the limb, 



gng ELEMENTS OF SITRGERY. 

I have no hesitation in recommending Mr. Home's ope- 
ration. 

« The operation for taking up the vena saphena is 
extremely simple, maybe performed in a very short time, 
and is attended with less pain, if we may judge from the 
account of those on whom it has been performed, than it 
would be natural to expect. My attention has been di- 
rected in every case in which it has been performed, to 
render it as little painful as possible, and the mode which 
appears to me the least so is the following : 

"As the veins are only turgid in the erect posture, 
the operation should be performed while the patient is 
standing ; and if placed on a table, upon which there is 
a chair, the back of the chair will serve him to rest upon, 
and he will have the knee joint at a very convenient 
height for the surgeon. The leg to be operated upon, 
must stand with the inner ankle facing the light, which 
will expose very advantageously the enlarged vena sa- 
phena, passing over the side of the knee joint. While 
the patient is in this posture, if a fold of the skin which 
is very loose at this part, is pinched up transversely, and 
kept in that position by the finger and thumb of the sur- 
geon on one side, and of an assistant on the other ; this 
fold may be divided by a pointed scalpel pushed through 
it with the back of the knife towards the limb, to pre- 
vent the vein being wounded ; much in the same way 
that the skin is divided in making an issue. This will 
expose the vein sufficiently, but there is commonly a thin 
membranous fascia, confining it in its situation : and 
when that is met with, the vein had better be laterally 
disengaged by the point of the knife. This is most ex- 
peditiously done by laying hold of the fascia with a pair 
of dissecting forceps, and dividing it ; for it is difficult 
to cut upon parts which give little resistance, and there 
is a risk of wounding the vein. After this, a silver crook- 



ELEMENT9 OF SURGERY. 391 

ed needle, with the point rounded off, will readily force 
its way through the cellular membrane connected with 
the vein, without any danger of wounding the vessel, and 
carry a ligature round it. This part, or indeed what may 
be considered the whole of the operation, being finished, 
the patient had better be put to bed, so as to allow the 
vein to be in its easiest stats before the ligature is tied, 
and then a knot is to be made upon the vein ; this gives 
some pain, but it is by no means severe. The edges of 
the wound in the skin are now to be brought together by 
sticking plaster, except where the ligature passes out, 
and a compress and bandage applied, so as to keep up a 
moderate degree of pressure upon the vein, both above 
and below the part included in the ligature. The in- 
flammation, in general, is very trifling; it does, however, 
in particular cases, extend for some way in the course of 
the veins under the skin; but even where this has hap- 
pened in the greatest extent, it has been attended with 
no bad consequences. The ligature comes away about 
the ninth or not later than the twelfth day, after which 
the parts commonly heal up. As it answers no good 
purpose for the ligature to remain so long, and only pro- 
tracts the cure, I have been in the habit of removing it 
on the fifth day, which saves the patient five or six days 
of confinement. The mode of removing the ligature is 
very simple ; the vein is so near the skin, that the knot 
is readily brought into view, and the ring of the ligature, 
which at the time of the operation was filled up by the 
vein, is now become loose, its contents having been con- 
siderably diminished by absorption, so that the point of 
a pair of scissors can be readily passed through it, by 
which it may with ease be divided, and the whole of the 
ligature brought away. 

"Cases occur in which there is a smaller vein run- 
ning parallel to the vena saphena. This, when the vena 



gog ELEMENTS OF SURGERY. 

sapheua has been taken up, afterwards becomes enlarg- 
ed, and continues the disease ; when that is the case, 
this vein also must be taken up. These circumstances 
ousht to be attended to in the first examination of the 
disease, as sometimes the two veins are so close together, 
that they may both be included in one ligature. 

" This enlargement of the vena saphena is sometimes 
combined with an enlargement of the branches of the 
vena saphena minor or posterior, that passes up behind, 
between the two hamstrings ; when this is the case, the 
disease is in an uncommon degree of violence, and in 
such instances would be less likely to be attended with 
success unless both venal trunks were taken up. 

" In two or three cases, there has been an enlargement 
of the branches of the vena saphena minor, without the 
vena saphena itself being at all affected ; the principal 
convolutions of the enlarged veins were on the calf of the 
leg, and on the outside of the foot, just below the outer 
ankle. In these instances there was no ulcer, and there- 
fore no very forcible reason could be urged to induce the 
patients to undergo an operation, nor was there the same 
chance of success, the use of a laced stocking was there- 
fore recommended ; and in case that should not answer, 
it was explained to them, that they had it in their power 
afterwards to have recourse to taking up the venal trunk. 

"The enlargement of the vena saphena minor, is 
rather mentioned as an uncommon occurrence, than as a 
case to be relieved by surgical treatment ; that when it is 
met with, it may be distinguished from the vena saphena, 
the subject under consideration. 

"In one case where there was an ulcer and only the 
branches of the vena saphena minor enlarged, the ulcer 
was situated more posteriorly than it is usually met with, 
and the branches upon the calf of the leg were in an ex- 
tremely varicose state, forming large projections, the 



ELEMENTS OF SURGERY. 393 

trunk itself was very large, while the vena saphena was 
nearly of its natural size. The patient was a young wo- 
man of a very delicate constitution, but in good health : 
she was twenty-five years of age, and suffered so much 
pain in the ulcer, and in the course of the enlarged 
branches, as to be unable to walk or stand for any length 
of time, unless the limb was supported by a bandage. 

" As instances occur, in which, though the immediate 
branches of the vena saphena are affected, the disease 
extends no further; and as the same thing happens, 
though less frequently, to the branches of the vena sa- 
phena minor ; and in other cases, the disease is found to 
take place in both, it becomes necessary to explain in 
what manner complicated cases may be distinguished. 

" The branches of the veins, passing up from the foot 
to form these two venal trunks, anastomose very fre* 
quently and freely with each other ; it is therefore im- 
possible to say precisely to which of them the collateral 
branches belong. 

" When the vena saphena becomes enlarged, many of 
the common branches, and some of those belonging to 
the posterior trunk, will consequently be affected ; and 
vice versa, when the vena saphena minor is enlarged. 
This, however, is not to be considered as implicating 
both veins in the disease, for the branches of one of them 
are only affected in a secondary way by their connection 
with the other. Whatever number of the venal branches 
of the lower part of the limb is enlarged, if this enlarge- 
ment in those of the upper part of the leg only extends 
in the course of one of the venal trunks, the disease 
should be referred to that trunk, which ever it is, as it 
is evident that the other, from its remaining of the natu- 
ral size, can have no part in the disease." (Home.) 

vol. 11. 8 k 



qqa ELEMENTS OF SURGERY. 



CHAPTER LVII. 

Ulcers attended with specific diseased actions. 

These are exceedingly numerous, and under the pre- 
sent division may be included all ulcers from a local or 
constitutional action of a morbid nature ;— all scrofulous, 
venereal, and cancerous ulcers, and probably many 
others. A dissertation on these complaints is not at pre- 
sent necessary, but as a general rule it will be proper 
where the constitution is affected, to apply those reme- 
dies which may be indicated by the nature of the disease, 
and when the morbid action is local, if possible, the dis- 
eased parts should be totally removed by the knife or 
caustic, and a simple ulcer will then be left which can be 
readily healed. 

I shall conclude by selecting from Mr. Home's valu- 
able work on ulcers, some observations on the present 
subject. 

I. OF THOSE ULCEUS WHICH YIELD TO MERCURY. 

" It is not meant as has been already stated to consi- 
der those ulcers that are connected with the venereal dis- 
ease, but such only as are produced by other diseases of 
the general system, or of the parts which yield to the ef- 
fects of this medicine. 

" It was natural when the beneficial effects of mercury 
in the venereal disease were first discovered to suppose 
that every complaint which yielded to mercury must be 
venereal. It was, however, to be expected that observa- 
tions accurately made would soon ascertain that this ac- 
tive medicine is capable of producing salutary effects in 



ELEMENTS OP SURGERY. 395 

many other diseases. Yet a long time elapsed before 
this was generally allowed. 

"Even now when it is universally admitted that mer- 
cury employed through the medium of the system is the 
most efficacious medicine in inflammation of the liver, 
and in diseases of many other of the viscera, surgeons 
very unwillingly give it credit for the cure of ulcers that 
are not venereal, but are inclined to suppose every ulcer 
that yields to such treatment, arises from that disease. 

" This is by no means true ; for many ulcers uncon- 
nected with the venereal disease which received no be- 
nefit from other medicines shall heal under a mercurial 
course, or yield to mercurial applications. In some cases 
the ulcer has remained stationary during the use of the 
mercury, but as soon as it was left off has put on a more 
kindly appearance, the mercurial course having produced 
so great a change in the constitution as to destroy the 
disposition which had kept the ulcer from healing. 

" Such ulcers are in general in their appearance al- 
lied to the indolent kind, but have some diseased dispo- 
sition peculiar to themselves. Mercurial frictions are in 
these cases to be preferred, as it is a material object to 
impair the constitution as little as possible, by leaving 
the stomach undisturbed and in a condition to take nou- 
rishment. 

" There are ulcers on the instep and foot with a very 
thickened edge, and a diseased state of the surrounding 
skin, approaching in their appearance to what is called 
elephantiasis ; these are frequently met with in servants 
of opulent families, where they had led an indolent life 
and fed upon a luxurious diet. In cases of this kind, 
fumigations with the hydrargyria sulphuratus ruber has 
healed the ulcers, and resolved in a great degree the 
swelling of the surrounding parts. 

" The mercurial ointment made either by calomel and 



gQQ ELEMENTS OF SURGERY. 

hogs-lard, or the unguentum hydrargyri mitius mixed 
with camphor answers in some cases better than any 
other application. 

"Camphor in general renders the mercury more ac- 
tive than when employed alone, and the mouth has been 
frequently known to be affected by an application of this 
kind to a small surface, when the mercurial ointment, 
applied to a much larger extent, has produced no such 
effect. 

" The hydrargyria muriatus, diluted with water, (to 
which a small portioti of spirit has been added) in the 
proportion of a grain to an ounce, is a very useful appli- 
cation to many ulcers with a diseased aspect, more par- 
ticularly those that are superficial, with a thickened 
edge, and appear to be principally confined to the skin." 

II. OF ULCERS WHICH YIELD TO THE USE OF THE DIFFERENT 
PREPARATIONS OF THE CONIUM MACULATUM, OR HEMLOCK. 

"The inspissated juice of the conium maculatum, in- 
ternally employed, is by some practitioners supposed to 
be entirely inert ; while by others it is believed to have 
considerable powers over many diseases. From these 
opinions, so diametrically opposite, and both taken from 
actual observation, it would seem that its effects are very 
precarious. I confess myself by no means warm in 
its favour ; for though it is sometimes of service in local 
complaints, it has so often failed, that much reliance 
cannot be placed upon it as an internal medicine, in dis- 
eases connected with surgery. 

" As an external application, the conium maculatum is 
a much more certain medicine, and I do not hesitate to 
declare myself convinced, that there are cases of diseased 
ulcers on the legs which are cured by it more readily 
than by other means. 

"The ulcers which are most generally benefited by 



ULBMttNTfl OF SURGERY. 39^7 

it, from their appearance, would be classed with the irri- 
table; but there is in the surrounding parts a degree of 
thickening, which must be attributed to some specific 
diseased action. These ulcers are met with in the neigh- 
bourhood of the ankle joint, and the joint itself is en- 
larged. They sometimes occur upon the ligaments of the 
joint of the knee, but less frequently. From their situa- 
tion and the enlargement of the joint, they may be sup- 
posed to be scrofulous ; but from their sensibility they 
must be considered as an uucommon variety, if they 
really belong to that disease. In such diseased ulcers 
the conium maculatum takes off the pain, reduces the 
swelling of the joint, and seems to counteract the dis- 
eased disposition, whatever may be its nature. 

" In many ulcers that are truly scrofulous, the exter- 
nal applications of the conium maculatum are productive 
of the greatest advantage, particularly in those attended 
with irritability. 

"The conium maculatum admits of being employed 
in three different forms, but only two of them are in ge- 
neral use. 

"The decoction is used as a fomentation, which is a 
very advantageous from, in those cases that are attended 
with pain ; since the warmth assists in soothing and alle- 
viating the symptoms. 

" It is used in the form of poultice, which has an ad- 
vantage, as it admits of being much longer continued to 
the ulcer. The decoction of which the poultice is made, 
should be much stronger than is commonly directed. 
Eight bundles, or four handfuls, of the dried herb, and 
a greater quantity of fresh leaves in proportion, should 
be boiled in a quart of water, to a pint. A poultice made 
with a weak decoction has frequently been used without 
the smallest benefit; but when the strength of the de- 
coction was increased, the ulcer shewed evident signs of 



398 ELEMENTS OF SURGERY. 

amendment. Where the weight of the poultice is oppres- 
sive to the limb, the decoction may be applied upon lint 
to the ulcer. v 

"The inspissated juice of the conium maculatum ad- 
mits readily of being formed into an ointment ; but al- 
though several trials have been made with it, the results 
were not in its favour as an external application. " 

OF ULCERS WHICH YIELD TO THE APPLICATION OF SALT 
WATER. 

"Salt water is an exceedingly good application in 
many scrofulous ulcers, some of them being more readily 
cured by it, than by other applications. The form of 
poultice is most commonly employed ; but in many cases 
of ulcers on the legs, keeping the part immersed in tepid 
salt water, for fifteen minutes, twice a day, appears to 
be preferable to any other mode. Several small ulcers 
have got well under this treatment in a fortnight which 
had resisted the effects of internal medicines, and many 
different external applications, for six months ; nor did 
the ulcers return afterwards in the course of several 
years. The same mode lias been used with large ulcers, 
and frequently with success. In scrofulous ulcers on the 
legs and feet, the salt water poultice sometimes brings 
out pimples on the skin, so that the application caunot 
be continued. When this is the case, adding equal parts 
of decoction of poppies takes off this unpleasant effect ; 
and after the skin has been for some time accustomed to 
the salt water in a diluted state, it will bear the salt wa- 
ter by itself. 

" In such cases the foot or leg at the times the poul- 
tice is to be changed will receive benefit by being im- 
mersed for ten minutes in tepid salt water. 

" In some superficial ulcers attended with a thicken- 



ELEMENTS OF SURGERY. 399 

ing of the skin, that have been in that state for months, 
the application of tepid salt water has produced a cure. 

" When there is an unusual coldness in the limb, 
without any tendency to mortification, the tepid salt wa- 
ter may be used with great advantage ; it brings a glow 
upon the skin, and rouses up the actions of the parts, so 
as to give an ulcer, which had for some time been in an 
inactive state, a disposition to heal. These cases occur 
in tall thin men who are unhealthy, and advanced in 
life. They are also met with in young women, who are 
very weak and unhealthy ; the whole system in such 
cases is apparently defective, not having sufficient ener- 
gy to do more than carry on the functions of life, and 
being therefore unable to support the effects of disease. 

" Where the leg has a tendency to become anasarcous, 
the application of tepid salt water is sometimes found 
entirely to remove that disposition." 

OF ULCERS WHICH YIELD TO THE USE OF THE ARGENTUM 
NITRATUM. 

" There is a species of ulcer which does not appear 
to go deeper than the cutis, but spreads in all directions, 
producing ulceration on the surface of the skin, and fre- 
quently extends in depth its whole thickness, or nearly 
so. This diseased disposition, whatever it is, does not 
remain in the parts that have ulcerated, but only on the 
edge of the skin, where the ulcer is increasing, for the 
surface first affected heals, while the skin beyond it is in 
a state of ulceration. 

" This description applies nearly equally well to the 
ulcers produced by three separate diseases, to all of which 
the soldier is peculiarly liable. One is a leprous erup- 
tion, most commonly met with among the impressed men 
brought from Ireland. Another is the consequence of 
buboes, which from their long continuance after the ve- 



400 ELEMENTS OF SttRGERY. 

nereal virus has been destroyed, dispose the skin to take 
on this disease. The third is a disease of warm cli- 
mates, commonly called the ring-worm. All of these as 
far as my experience enables me to form an opinion, 
yield more readily to the solution of the argentum nitra- 
tnm applied to them in different proportions, than to any 
other local treatment. 

" The disease met with among the Irish recruits is 
evidently of the leprous kind, as it is communicated by 
infection; and in those instances that have come under 
my care, was received by lying in bed with persons af- 
fected by it. Under these circumstances, a vulgar per- 
judice of its only affecting parts similar to those that had 
the disease, is very readily explained, for such similar 
parts in bed are the most likely to come into contact with 
each other. 

" It affects in general the breast, back, and legs ; it 
shows itself by a swelling like a large boil, with a pale 
red margin, extending for some way all round ; a reddish 
black scale forms on the top, the boil becomes extremely 
painful and itches ; the scales fall off exposing a foul ul- 
cer, which discharges a fetid limpid fluid, and excoriates 
the surrounding skin, producing ulceration wherever it 
comes in contact : in this way it spreads over the greater 
part of the limb, and in some instances over a consider- 
able portion of the body ; the parts first affected healing, 
while the disease is extending to those beyond. These 
ulcers remain open, three, four or even six months, and 
then heal up leaving a cicatrix similar to that which re- 
mains after the small pox ; these cicatrices often break 
out again in the spring in the same way that the disease 
first began, by forming a boil, which becomes an ulcer 
and spreads as it did before. In the very hot weather 
the pain and quantity of the discharge are the greatest ; 
so that in the month of June the disease is the most vi- 
rulent and in the autumn subsides. 



ELEMENTS OF SURGERY. 401 

"The symptoms are aggravated by the use of spi- 
rituous liquors, by feeding on salt provisions, and catch- 
ing cold; under any of these circumstances the ulcers 
are more inflamed and the pain more violent. 

" A number of cases of this kind came under my care 
in the year 1778 at the naval hospital at Plymouth, be- 
ing brought from Ireland, among the men impressed for 
the use of the navy. Mild applications did not answer ; 
more stimulating medicines gave relief ; and the solution 
of the argentum nitratum appeared upon the whole to be 
the best adapted to this disease. 

The disease in the skin produced by the effects of 
very irritable buboes, in constitutions broken down by 
mercury, is very similar in its progress to that which has 
been described ; it is, however, more violent, the ulcera- 
tion going deeper than the skin, which makes it more 
painful : it spreads in some cases down the greater part 
of the thigh, and upwards almost around the body. The 
new skin which forms is readily disposed to ulceration, 
and the parts break out again very commonly in the 
spring. The discharge is of a thin acrid kind ; and as it 
excoriates the surrounding skin, there is little doubt but 
it would affect the skin of another person. 

" In several cases of this kind, a variety of applica- 
tions have been tried, but none of them agreed with the 
skin so well as the argentum nitratum; all preparations 
of mercury did harm ; no unctuous application auswer- 
ed, so that it was always necessary to return to tbe ar- 
gentum nitratum ; and by steadily persevering in its use, 
even in the worst of them, a cure was nearly effected, 
after a continuance of the disease for nine months pre- 
vious to its being applied. 

"The ring-worm is considered as a disease of warm 
climates ; and in the stage where an nicer is formed, it 
certainly is confined to hot countries ; it is, however, met 
VOL. II. ** F 



4kQ«j ELEMENTS OF SURGERY. 

with iu a less degree in the warm season in England. 
It is supposed to be infectious, and always to be caught 
in that way; that it is so generally, there can be no 
doubt, but it also arises very commonly without any in- 
fection : this however, probably happens where the skin 
is very readily affected by the disease. That infection 
is not necessary for the production of the ring-worm, is 
proved by the following instances where it arose sponta- 
neously. 

" In the summer 1779, while at Plymouth, I was con- 
sulted by an officer in the 75th regiment, at the desire 
of Mr. Venven, who was then surgeon of it, for a com- 
plaint on the skin of the upper part of the thigh, which 
appeared an uncommon disease, and did not yield to 
any applications that were made to it. I felt myself 
equally at a loss in what view to consider it ; mercury 
was used in different forms, but without any good effect, 
and in the autumn it very gradually went off. 

" About a year after seeing this case, I embarked for 
the West Indies, and as soon as the ship had got within 
the tropics, found myself more oppressed and irritated by 
the heat than most of the Europeans on board, and to 
my astonishment found a similar complaint had taken 
place to that under which the officer had laboured, at 
Plymouth. To allay the extreme pain and itching it 
produced, cold water was frequently applied to the part, 
which kept it very cool; under this treatment it went off, 
but not for several weeks. Upon my arrival in the West 
Indies, the disease returned, and was ascertained to be 
the ring-worm, so common in that country, which it was 
impossible for me or the officer of the 75th regiment at 
Plymouth to have received by infection. 

"The ring- worm begins with an efflorescence on the 
skin, a little raised above the natural level, which 
spreads from a centre ; when the disease increases in 



ELEMENTS OF SURGERY. 4Q3 

violence, the margin of the circle is raised into a welt, 
and the surface contained in it appears scurfy ; the welt 
becomes covered with a scab which falls off, exposing 
an ulcerated ring, commonly not more than a quarter of 
an inch broad ; the ulceration spreads outwardly, and 
heals towards the centre ; so that in general the breadth 
of the ulceration is nearly the same, although the circle 
is becoming larger and larger. It seldom becomes of any 
depth, being entirely confined to the cutis ; but in the 
worst cases it appears to extend through its whole thick- 
ness. In this stage it must be classed among the dis- 
eased ulcers, and among those of a very distressing kind, 
as the painful symptoms are very violent. The discharge 
is not pus, but a thin watery fluid, of a very acrid nature, 
which by its virulent properties, most probably extends 
the disease along the skin. 

"In the East Indies the application in use to it, in 
this stage, is vinegar saturated with borax. The na- 
tives employ the juice of some plants, which is sold as 
a secret medicine ; it is made by a Hindoo doctor at Vi- 
zagapatam, and sold at the different presidencies in In- 
dia. This medicine is of a very acrid nature, giving the 
patient excruciating pain, but removes the disease in a 
very short time. 

" The solution of the argentum nitratum answers in 
the milder cases, and there is little doubt of its being 
equally successful in those that are more severe." 

OF ULCERS THAT YIELD TO THE USE OF ARSENIC. 

i* Arsenic has been applied externally in cases of can- 
cer, by a number of empyrics, as a caustic ; but from the 
violence of its effects, regular practitioners have in ge- 
neral been afraid to employ it in cases of surgery. It is, 
however, a medicine that may be used with safety, both 
internally and externally, in many diseased ulcers, with 
the greatest advantage. 



404< ELEMENTS OF SURGERY. 

" Those ulcers in which I have been led to employ it, 
are named from the virulence of their disposition, noli 
me tangere ; and are very nearly allied to cancer : dif- 
fering from it in not contaminating the neighbouring parts 
by absorption, but only spreading by immediate con- 
tact. 

"Ulcers of this kind differ exceedingly from one ano- 
ther in their degree of virulence ; but they are all so far 
of the same nature, that arsenic in general agrees with 
them, and puts a stop to their progress, while they are 
aggravated by milder dressings. 

i( I have been in the habit, for many years, of using ar- 
senic externally to such ulcers, and its effects encouraged 
me to continue this practice; but did not authorize giving 
it internally with this view, lest the quantity necessary 
to be of any service might prove hurtful to the coats of 
the stomach. I was, however, induced to try it some 
years ago in St. George's hospital, iu the following case, 
in which nothing could be well applied to the part it- 
self. 

e< A woman, sixty-five years of age, came into St. 
Greorge's hospital on the 15th of June, 179(5, with an 
ulcer on the side of the tongue, of three months continu- 
ance. It was foul, and was spreading backwards to the 
root of the tongue, was extremely painful, and the ulcer 
had an offensive smell. It was out of the reach of ex- 
ternal application. Finding no advantage from the use 
of the extract of the conium maculatum, which was given 
in large doses, it was thought right to try the solution of 
white arsenic in boiling water. She took at bed time 
five drops for a dose ; this made her very sick : next 
night three drops were given, which did not disturb her 
stomach; this dose was continued for four successive 
nights, and as the stomach was very quiet, the number of 
drops was again increased to five, which were now found 



ELEMENTS OF SURGERY. 4Qg 

to agree very well. The ulcer was evidently better, and 
at the end of three weeks from the time the arsenic was 
given, was much diminished in size. The dose was in- 
creased to six drops, and in a fortnight more the ulcer 
was completely healed. The arsenic in this case could 
not act locally, as the ulcer was not situated upon a part 
of the tongue to which it could apply itself in the act of 
swallowing, and if it had, the time of application must 
have been too short to produce much effect. 

" The success attending this case induced me to try the 
internal use of arsenic for an ulcer upon the side of the 
nose of a young woman, which had much the appearance 
of the noli me tangere. Nothing was externally applied, 
the whole treatment consisted in the internal use of arse- 
nic, and in the course of a few w r eeks the nose was nearly 
healed. 

" These not being cases of ulcers on the legs, may be 
considered as foreign to the present subject ; but they are 
here introduced with a view to justify the internal use of 
arsenic in those ulcers on the leg, which receive benefit 
from its external application ; since they show, in the 
most unequivocal manner, that such practice is in itself 
not only safe, but capable of being attended with great 
advantage. 

" To ulcers of an untoward appearance on the legs, ar- 
senic may be used both internally and externally, with 
success. 

" The cases to which this treatment is peculiarly appli- 
cable, are those of the fungated ulcer. They are met 
with in the calf of the leg, and on the sole of the foot, 
shooting out a fungus from the surface, which is entirely 
different from common granulations : the new formed sub- 
stance is radiated from its structure, the bottom of the 
ulcer being the central point, and the external surface 
(which is always increasing) the circumference. This 



£05 ELEMENTS OF SURGERY. 

fungus is very tender in its substance, and bleeds if the 
slightest violence is committed on it. This disease in 
its origin sometimes appears like a scrofulous affection of 
the metatarsal bones of the foot; but the enlargement of 
the parts exceeds what commonly is met with in scrofula, 
ulceration takes place upon the skin, and a fungus shoots 
out, showiug, for the first time, the nature, of the disease. 
Whether such cases are originally scrofulous, and after- 
wards assume the new diseased disposition, it is diffi- 
cult to determine ; but their remaining for a year before 
the fungus shows itself, renders it highly probable. The 
same disease takes place in the testicle. 

"There appear to be two kinds of this disease; one 
which is poisonous, and capable of contaminating the 
lymphatic glands in the course of absorption ; the other 
not. There is no mode by which these two species can 
be distinguished in their earlier stages ; and the first 
kind is not to be removed by this or any other application, 
at present known : it is therefore only in the second kind 
that the arsenic is capable of effecting a cure. This me- 
dicine should however, be used in all cases not ascertain- 
ed to be poisonous. 

" The solution of arsenic, which I have always used, is 
made by boiling white arsenic in water for several hours 
in a sand heat, and taking this saturated solution for use. 
When given internally the dose is from three drops to ten, 
when externally applied, a drachm is diluted with lb. ij 
of water ; and the solution is gradually made stronger, 
as the parts become accustomed to it, till it is of double 
strength. This solution is either applied on lint, or made 
into a poultice. 

"In ulcers connected with diseased bone, which pre- 
vents them from healing, the luxuriant granulations rise 
up round the orifice leading to the bone, and require be- 
ing destroyed by some escharotic ; the solution of arse- 



ELEMENTS OF SURGERY. 407 

nic answers this purpose better than any of those in com- 
mon use." (Home.) 

In the treatment of ulcers attended with specific action, 
as in all others the state of the system must be always 
kept in view. If an inflammatory disposition be mani- 
fested, the remedies for inflammation must be adminis- 
tered ; if, on the contrary, great debility prevail, an in- 
vigorating diet and tonics are to be directed. The in- 
fluence of the general health upon all ulcers is very great ; 
an epidemic will sometimes occasion every ulcer in a 
large hospital to " wear its livery," and until this morbid 
diathesis is removed, the ulcers cannot be cured. The 
surgeon should therefore never lose sight of the itate 
of the system. 



408 ELEMENTS OF SURGEIlT, 

CHAPTER LVIII. 

Of Caries. 

Having treated of ulcers in the soft parts we proceed 
to speak of caries, which consists in ulceration of a bone, 
and is analogous to the same process in soft parts, the 
action of the absorbents being essential in both cases. 

Every bone in the body is occasionally affected with 
caries ; the spongy bones, however, more frequently than 
the rest; the bones of the tarsus and carpus, the sternum, 
and the vertebrae are most liable to caries, and when it 
attacks the long bones, their spongy extermities are ge- 
nerally affected. The bones in early age are more lia- 
ble to caries than in advanced life. 

The substance of a bone affected with caries becomes 
soft, so that a probe may readily be forced into it. Fun- 
gous flesh forms around it, which is exceedingly vas- 
cular and bleeds whenever it is touched. A serous 
discharge takes place, of a black colour and offensive 
smell. Caries differs from necrosis as ulcer differs 
from gangrene. In caries there is action, and the absor- 
bents remove the diseased bone ; in necrosis the bone is 
dead, and the absorbents of the neighbouring living bone 
detach it, as a slough or eschar is detached in the soft 
parts. 

Caries is produced by a great variety of causes ; it 
seldom, however, results from external violence, because 
a blow on a bone, if sufficiently forcible, occasions ne- 
crosis ; but caries sometimes results from blows, and ac- 
cording to Boyer it is produced by an extravasation of 
blood into the cells of the bone, and the inability of the 
absorbents to remove the effused blood which occasions 
ulceration or caries. 



ELEMENTS OF SURGERY. ■ 4$$ 

"Abscesses are said to occasion sometimes a caries of 
the bones, over which they take place ; and we are told, 
that the existence of the morbid state of the bone may 
be ascertained by introducing a probe to the bottom of the 
abscess. 

•" Conformably to this theory, it has been laid down 
as a rule, that abscesses situated over bones should be 
opened at an early period, in order to prevent any disor- 
der of the bone or periosteum from the stagnation of the 
purulent matter. But if abscesses formed over certain 
bones, as, for instance, over the anterior face of the ti- 
bia, or mastoid process of the temporal bone, be fre- 
quently accompanied with caries, the latter is the cause, 
and not a consequence of the abscess. Pus, which is a 
bland, unctuous, and inodorous fluid, never attacks the 
soft parts with which it is in contact, until its qualities 
are changed by exposure to the air. When an abscess 
forms in the anterior parietes of the abdomen, the peri- 
toneum naturally a thin membrane, instead of being cor- 
roded, becomes thick and strong enough to resist the ef- 
fusion of the pus into the cavity of the abdomen. The 
periosteum becomes thickened in similar circumstances, 
when the abscess is a consequence of an external injury. 
We may conclude, then, that caries is seldom produced 
by an external cause ; and that most frequently a blow 
or external injury, when followed by that disease, has 
acted only as an exciting cause, a disposition to it hav- 
ing pre-existed. There is every reason to believe that 
it may be ascribed in almost all cases to a disease of the 
system, such as scrofula, lues, scurvy, or even cancer. 

"Scurvy diminishes the energy of the contractile 
fibre, and diffuses a principle of dissolution in the solids 
and fluids. The blood rendered more fluid by it than 
natural, oozes through the pores of its small vessels : 
spots or ecchymoses manifest themselves, first in the 

vol. ir. 3 g 



^10 ELEMENTS OF SURGERY. 

parts in which circulation is most languid, as on the 
hands and feet: the muscles become soft and painful; 
the gums swell, and separate from the alveolar process : 
the periosteum may become tumefied in like manner, and 
lose its connexion with the bone affected with caries. 

" Scrofula attacks the spongy part of bones and the 
lymphatic system. A caries from this cause is very fre- 
quent in the tarsus, carpus, elbow, and knee ; but it is 
always preceded by a white swelling. 

"The venereal disease is sometimes a cause of caries, 
though its action on the osseous system more generally 
produces uecrosis or exostosis. However, when it at- 
tacks the bones of the nose, it produces a caries of them, 
by which they are consumed, and the face sadly disfi- 
gured. The bones of the palate are sometimes destroy- 
ed in the same manner, and by the same cause. 

" In cancers of the mammae, the sides of the sternum 
are often found carious ; which proves that cancerous nh 
cers may, as well as the preceding diseases, occasion a 
caries of the bones in their neighbourhood. 

"Nothing can be easier than to ascertain the exist- 
ence of a superficial caries ; and when the affected bone 
is deep-seated, it may be discovered by introducing a 
probe ; for if the bone be carious, the probe may be easi- 
ly forced into its substance. But bones which we can- 
not readily come at may be carious, in which case the 
diagnosis is somewhat more difficult ; however, if a fistu- 
la, from which a fetid blackish matter flows, be directed 
towards a bone, and if the surrounding soft parts be at 
the same time turgid and indurated, there is every reason 
to apprehend a caries. The black colour of the dis- 
charge is, however, equivocal ; because, as remarked by 
Ambrose Pare, it may be occasioned by a bit of agaric 
or other foreign body introduced into the wound. It will 
be prudent, therefore, in dubious cases, to trust chiefly 
to the history of the disease. 



ELEMENTS OP SURGERY. 444 

"If a persons affected with a certain constitutional dis- 
ease, feel deep-seated and acute pains in any of his 
bones ; and if the pained part swell and become the seat 
of an abscess, from which a purulent matter of a bad 
quality flows, there is every reason to believe that the 
bone affected with pain is carious. Inert abscesses are 
attended with nearly the same symptoms, with this dif- 
ference, that they are not preceded by pain. Caries oc- 
casioned by syphilis affects most commonly the tibia, o.s 
frontis, ossa nasi, ossa palati, and sternum. Whenever, 
therefore, any of these bones become carious, whilst the 
person labours under syphilis, there is just ground for 
concluding that the caries is a symptom of the venereal 
affection. 

" A caries of the vertebrae is known by peculiar symp- 
toms, among which a paralysis of the inferior extremi- 
ties, and the formation of abscesses in the groin, verge of 
the anus, or lumbar region, are the most remarkable. 

" The prognosis is more unfavourable in cases of ca- 
ries of spongy bones, than in those of a similar affection 
of compact ones, thus there is not so much to be appre- 
hended when the bones of the cranium or the scapulae 
are affected, as when the extremities of long bones are 
similarly diseased. Caries of the bones of the carpus 
and tarsus is also very dangerous. The evil, on account 
of these bones being in such close contact, extends from 
one to the other; and when one of them becomes carious, 
it is very difficult to stop the progress of the disease with- 
out amputating the limb. 

"This operation is often the only resource in our 
power against caries of short bones, or of the extremi- 
ties of long ones ; and we are even deprived of this when 
the bone affected with it is deep-seated : thus caries of 
the head of the femur, or of the cotyloid cavity, cannot 
fie remedied by this operation. The same may be said 



$12 ELEMENTS OF SURGERY. 

of caries of the spine, also named gibbosity, in which, 
as well as in the preceding case, our treatment must be 
merely palliative.* 

" Caries from an external cause is less dangerous as 
well as less frequent than that from an internal ; and 
that resulting from an internal disposition is much more 
dangerous when it proceeds from a scrofulous or cancer- 
ous diathesis, than from a venereal or scorbutic ; for 
some efficacious remedies against the latter are known ; 
but cancer and scrofula resist all the remedies with 
which we are as yet acquainted. It is also more danger- 
ous to old than to young persons, not that its progress 
is not more rapid in the latter, as already mentioned, but 
because nature is more capable of limiting its ravages in 
youth than in old age. Finally, the prognosis is further in- 
fluenced by the extent of the disease, the patient's strength, 
and state of the neighbouring soft parts." (Boyer.) 

TREATMENT. 

In the treatment of caries much depends on the source 
or cause of the disease. If any peculiar morbid affec- 
tion of the system exist, this must be previously reme- 
died. If the venereal disease have produced the affec- 
tion, mercury must be administered. The caries, how- 
ever, which results from the venereal disease, is by no 
means to be considered as indicative of the presence«of 
venereal action, because, after the bone has become 
carious, it is possible for the venereal action to be com- 
pletely removed by the use of mercury without an imme- 
diate separation of the bone. It is to be remarked here, 
however, that although caries sometimes results from 
the venereal disease, yet, it oftener happens, chat por- 
tions of bone are completely killed, and exfoliate in con- 

* Not always: there is reason to believe it sometimes cured. Seethe Chap- 
te* on •« Curved Spine." 



ELEMENTS OF SURGERY. 4»18 

siderable masses after the venereal disease is cured. It 
is uo uncommon thing to find the ossa spongiosa coming 
away almost entire ; large portions of the alveolar pro- 
cess of the upper jaw, the vomer, and other masses of 
bone, are often detached by the absorbent vessels, in 
consequence of venereal affections which have been 
previously cured by the administration of mercury. 

To remove the diseased action of the system, which 
had produced the caries appears in such cases to be all 
that is necessary, the parts readily heal when this is done, 
" Causa sublata tollitur effectus." As I shall not enter 
on the treatment of the venereal disease on the present 
occasion I refer to Dr. Adams 7 excellent edition of Mr. 
Hunter's treatise on that subject in which the proper 
mode of administering mercury is most judiciously de- 
tailed. The time necessary for the separation of por- 
tions of bone which have been destroyed by syphilis, 
varies considerably, and is sometimes extremely tedious. 

If the caries have arisen from scurvy, the remedies 
for this disease are to be administered. A vegetable 
diet with acid drinks are to be prescribed. 

Where the disease, however, is local, local remedies 
are to be applied. It is an important principle in the 
treatment of certain ulcers, to destroy the life of the dis- 
eased parts, so that an eschar may be formed, and when 
the eschar separates, a common healthy sore may be 
left. In like manner a carious bone may often be treated 
with advantage. Lunar caustic is to be applied with 
this view to the carious part, by which it will be reduced 
to the state of a necrosis or mortified bone, which will 
be detached by the action of the absorbents, and the 
healthy bone left underneath in general granulates and 
heals. 

The French surgeons in many cases, especially in 
what they denominate a humid caries, which is attended 



^^ ELEMENTS OF SURGERY. 

with a copious serous discharge, prefer the actual cau- 
tery to the lunar or vegetable caustic. The following 
remarks from Boyer on its use are entitled to great at- 
tention. « This remedy is applicable to every case of 
humid caries where the surrounding soft parts have not 
a manifest tendency to cancer. Sometimes, however, 
the soft parts surrounding a carious bone have that ten- 
dency in so advanced a degree, that the actual cautery 
would necessarily occasion the developement of that 
morbid state. The general rules to which the use of the 
actual cautery may be reduced are as follow : 

" In the first place, all the carious part of the bone 
must be laid bare, whether by cutting away the soft 
parts, or destroying them by caustic. The latter me- 
thod being tedious, inconvenient, and uncertain, should 
not be used unless when the patient will not submit to 
the knife. The bone being in this manner laid bare and 
scraped, the surgeon provides himself with several 
eauterizing irons of the same form, because the applica- 
tion of one is seldom sufficient. It will also be necessary 
to provide a number of cannlse when the cautery is to be 
applied on a bone from about which the soft parts cannot 
be completely raised ; as, for instance, on the os coccygis, 
or sacrum : by means of these canulse, the hot iron can 
be introduced without injuring the soft parts. In every 
case it will be necessary to protect the surrounding parts 
as much as possible from the action of the cautery. 

"The iron, whatever may be its size, should be heated 
white, as the hotter it is, the more rapid and less painful 
is its action. On the instant of its application, a black 
thick smoke rises from the surface of the burning bone, 
the smell of which resembles exactly that of burning 
horn : the great quantity of sanies quickly diminishes the 
heat ; for which reason a second is to be immediately 
applied with the same precautions : and a third, if the 



ELEMENTS OF SURGERY. 415 

two preceding have not burned deep enough. Care should 
be taken to extirpate the disease by burning every part 
that is affected ; aud if the use of the cautery has not 
always had the success expected from it, the failure of 
it is to be attributed to the timidity of the operator. A 
carious bone becomes worse by the application of the 
actual cautery, if the evil be not entirely rooted out, just 
as a cancerous tumour becomes irritated, and makes a 
more rapid progress, if imperfectly cauterized. 

" The actual cautery acts by evaporating the noxious 
fluids in which the carious bone was immersed ; by 
changing the caries into necrosis, and by irritating the 
subjacent sound parts, and exciting that action of the 
vessels by which the dead part of the bone must be 
thrown off/*' 

The particular situation of a bone often influences the 
treatment necessary. The skull sometimes becomes ca- 
rious in consequence of the venereal disease, and here 
the actual cautery cannot be applied. The trepan is 
therefore to be used, and with it the diseased or dead 
bone is to be removed. Boyer recommends, however, 
the application of the hot iron, when the mastoid pro- 
cess of the temporal bone is the part affected, because the 
thickness of its substance is sufficient to protect the brain 
from the effects of the heat. 

The bones of the face are not often affected with ca- 
ries, except from scurvy or syphilis, and the constitu- 
tional remedies for these diseases generally effect a cure- 
Caries of the vertebrae has already been particularly 
noticed. 

A caries of the sternum is not unfrequent. The affect- 
ed bone should, if possible, be removed by means of a 
trephine, or cutting instruments. The internal mam- 
mary artery should be carefully avoided in the operation, 
although it could probably be secured if wounded. After 



440 ELEMENTS OF SURGERY. 

trepanning the sternum, the pleura beneath it is found to 
thicken and gradually becomes hard and cartilaginous, 
supplying in some measure the deficient bone. Boyer 
recommends after the wound is completely healed, the 
application of firm leather or pasteboard, over the aper- 
ure for the purpose of defending the contents of the tho- 
rax from accidents. He adds, " if the carious part can- 
not be totally removed, it will be necessary to make twa 
perforations in the lower part of the sternum in order to 
give a free passage to the purulent matter. Though the 
disease will not be radically removed by this means, yet 
the sufferings of the patient will be considerably alle- 
viated." 

In the other bones, especially in those of the extremi- 
ties, the carious part, when practicable, should be remov- 
ed by means of a trephine or Hey's saw, together with 
chisels, gouges and knives ; but if this cannot be done, 
the caustic, or hot iron, should be used. Large portions 
of carious bone have been removed by these instruments 
in a variety of cases, with the effect of producing a 
speedy cure. 



ELEMENTS OF SURGERY. 417 

CHAPTER LIX. 

Of Necrosis. 

Necrosis as has already been mentioned, denotes the 
entire dtvth of a bone or part of a bone. 

All the bones are occasionally affected by necrosis. 
The affection may be partial or total. It may be super- 
ficial or extend through the whole thickness of the 
bone. 

" The middle portion of long bones, or that part of 
them, which is most compact, least porous, and conse- 
quently least endued with the vital principle, is that 
which necrosis most generally attacks. The extremi- 
ties of these bones, and in general, all spongy bones are 
much less liable to it. It never extends to the articula- 
tions even when the whole diameter of the middle part 
of the bone is affected by it. The extremities covered 
with cartilage separate from the dead part of the bone, 
and if this be removed by nature or art, they unite with 
the ossified periosteum which occupies the place of the 
separated portion. 

" When the necrosis is superficial, the superior la- 
mellae are separated from the rest of the bone ; but this 
separation is always preceded by a suppuration pro- 
duced by the irritation given to the surrounding soft parts 
by the dead portion of bone. It is to be observed, that 
no part of the substance of the dead portion of bone goes 
to the formation of this purulent matter; for it seems to 
be not only incapable of furnishing matter for formation 
of pus, but is entirely without the sphere of vital action. 

" If a broad bone as the os frootis, for instance, be 
attacked, the skin over the affected parts tumefies, be- 

VOL. II. 3 H 



418 ELEMENTS OF SURGERY. 

comes inflamed, and assumes a brown or violet colour ; 
it grows gradually thinner, bursts at length, and gives 
issue to the purulent matter contained under it. The 
necrosis of the bone is then ascertained by introducing a 
probe, which is found to pass on a rough and naked sur- 
face, if the affection of the bone really exist. 

" In a case of complete necrosis of a long bone, the 
limb swells at the part affected, and a hard tumour is 
formed on it. Abscesses form at various points, they 
burst, and their openings degenerate into iistulse. The 
discharge from these in the commencement is white and 
inodorous, but becomes serous and fetid in a short time. 
This matter is sometimes absorbed in such quantity as 
to produce marasmus, hectic fever, &c. In cases of ne- 
crosis, in which the whole bone is affected, the perios- 
teum separates from the portion of diseased bone, its ves- 
sels seem to take on a new action, a calcareous phosphate 
is deposited in its texture, it acquires hardness, and in 
time forms a cylinder, in which the dead part of the bone 
is included. This new bone, which is in fact the peri- 
osteum ossified, is rough on its surface, and has but a 
distant resemblance to that which it replaces. Various 
holes are observed in it, through which the purulent 
matter and mouldering portions of bone escape, the fistu- 
lous openings in the soft parts being continuations of 
these holes, and the muscles of the limbs are inserted 
into it. 

" The dead part, completely separated from the sound, 
and enclosed by the indurated periosteum, is called the se- 
questrum ; this separation is perfectly analogous to that of 
mortified soft parts. 

" The promptitude with which gangrened soft parts 
are separated, is much greater than that with which a 
dead portion of bone is detached ; but this difference is 
to be entirely attributed to the state of the vital energy of 



ELEMENTS OP SURGERY. 41 Q 

the parts, which is much more considerable in the one 
case than in the other." 

The causes of necrosis are various accidents by which 
the texture of a bone is destroyed, as blows, pressure, 
&c. and also certain diseases, as syphilis, scrofula, &c. 
indeed it is difficult to distinguish, when caries, and 
when necrosis have resulted from these constitutional af- 
fections ; and it is unnecessary to add to what has been 
said of their effects in the last chapter. 

Some of the most interesting operations of the ani- 
mal economy are called forth by necrosis. The manner 
in which new bone is formed to supply that which has 
been lost, has of late years excited great attention, and 
appears at present to be well understood . 

It frequently happens that the firmness of a limb re- 
mains during the whole of the process by which the new 
bone is formed ; it would appear from the observations of 
Mr. Russell, that the old bone serves as a mould upon 
which the new bone is formed, and the new bone not 
only begins to grow, but actually acquires solidity and 
firmness before the dead bone is absorbed and removed ; I 
have before me at this time a very curious specimen of 
new bone, investing completely in a hollow cylinder 
a portion of carious tibia, an aperture remaining in front 
nearly large enough to permit the extraction of the old 
bone. And a case is recorded in which seven inches of the 
thi"-h bone was pulled away from within a similar bony 
production in a boy thirteen years old. In some cases 
a complete new clavicle has been formed, the old one 
being separated, and large portions of the lower jaw 
bone have been regenerated after being destroyed by 

necrosis. 

If the new bone were not formed previously to the 
separation of the old, the limb would become flexible at 
the diseased part. 



^20 ELEMENTS OF SURGERY. 

It has already been remarked that necrosis generally 
happens in the middle of the cylindrical bones., and that 
the articulating extremities remain sound. From these 
extremities the formation of new bone progresses upon 
the old, forming a case around it, larger in diameter, 
of course, than the old bone, but never exceeding it in 
length. This bony involucrum is at first a soft pulpy 
mass, and Mr. Russell supposes it formed independently 
of the original bone, or its periosteum. Mr. Macartney op- 
poses this idea, and in a letter published by Mr. Crowther, 
remarks, " that the first and most important circumstance 
is the change which takes place in the organization of 
the periosteum ; this membrane acquires the highest de- 
gree of vascularity, becomes considerably thickened, 
soft, spongy, and loosely adherent to the bone. The 
cellular substance, also, which is immediately connected 
with the periosteum, suffers a similar alteration : it puts 
on the appearance of being inflamed, its vessels enlarge, 
lymph is shed into its interstices, and it becomes conso- 
lidated with the periosteum. These changes are prepa- 
ratory to the absorption of the old bone, and the secretion 
of new osseous matter, and even previous to the death of 
the bone, which is to be removed. In one instance, I 
found the periosteum vascular and pulpy, when the only 
affection was a small abscess of the medulla, the bone 
still retaining its connection with the neighbouring parts, 
as it readily received injection. The newly organized 
periosteum, &c. separates entirely from the bone, after 
which it begins to remove the latter by absorption;" and, 
while this is going on, its inner surface becomes covered 
with little eminences, resembling granulations. "In 
proportion as the old bone is removed, new osseous mat- 
ter is dispersed in the substance of the granulations, 
whilst they continue to grow upon the old bone, until the 
whole, or a part of it, is completely absorbed, accord- 



ELEMENTS OF STTRGERY. 4&1 

ing to the circumstances of the case. What remains of 
the investment, after the absorption of the old bone, and 
the formation of the osseous tube, which is to replace it, 
degenerates, loses its vascularity, and appears like a 
lacerated membrane. I have never had an opportunity 
of examining a limb, a sufficient time after the termina- 
tion of the disease, to ascertain, whether the invest- 
ment be at last totally absorbed; but, in some in- 
stances, I have seen very little remaining. During the 
progress of the disease, the thickened cellular substance 
which surrounded the original periosteum, becomes gra- 
dually thinner, its vessels diminish, and it adheres strict- 
ly to the uew formed bone, to which it ultimately serves 
as a periosteum." 

The symptoms of necrosis have been well described 
by Russell. In an incipient state, it is characterized by 
a deep-seated excruciating pain, not at first aggravated 
by pressure, and which is soon followed by a rapid en- 
largement of the parts along the course of the bone. 
Soon, however, after the commencement of the attack, 
an external inflammation succeeds, which quickly ends 
in the formation of matter. The abscess, at length, 
bursts by a small opening. The extent of this inflam- 
mation is not in general great. Most commonly several 
inflammations, of a circumscribed kind, occur about the 
same time, the abscesses burst by small openings, which 
do not close, but continue discharging matter as fistulous 
sores. The apertures are generally situated over the 
most superficial part of the affected bone. The pus is 
usually of good quality, and large in quantity, issuing 
from extensive cavities, into which the fistulse lead. .Such 
abscesses, being situated within the newly formed osseous 
shell, cannot be discharged by pressure, nor can any 
fluctuation be felt. A probe can seldom be introduced 
far into the fistulous openings, or discover any loose piece 



488 ELEMENTS OF SURGERY. 

of bone. In this stage, the dead bone, technically called 
the sequestrum, can seldom be felt, though, in a few in- 
stances, small spiculae make their way outward, together 
with the discharge. Fistulous openings may be regard- 
ed as necessarily attendant on all cases of necrosis; 
though so mild a case may be conceived, that the new 
bone may be generated without any outward ulcerations. 
No such iustance, however, is on record." 

After the openings have formed, the case may take 
one of the two following courses. The ulcerations may in 
time heal up, the sequestrum never be seen, and no ves- 
tige of the disease remain, except a permanent enlarge- 
ment and induration along the course of the bone, — this 
is the most favourable manner, in which a necrosis can 
terminate ; or secondly, the sequestrum may make its 
appearance externally, through the new bone and the in- 
teguments, attended with degrees of pain, inflammation, 
and suppuration, differing in different cases. The 
sequestrum may at first be moved by shaking it; bufc is 
too firmly wedged in the surrounding parts to be com- 
pletely taken out. In time, however, it becomes loose 
enough to be removed. 

Sometimes, the middle portion of the sequestrum pre- 
sents itself externally, while its sides are every where 
wedged in the substance of the new bone. The natural 
end of such a case would be very tedious of accomplish- 
ment, and the interference of art is essentially service- 
able in accelerating the separation of the dead bone, thus 
circumstanced. After the sequestrum has been either 
absorbed or thrown off, in one of the above ways, the 
cavity of the new bone becomes filled up with granula- 
tions, which are, at length, converted into bony matter. 
Thus the new bone differs from the original one, in be- 
ing solid instead of hollow. 

" When the sequestrum is thrown off slowly, the in- 



ELEMENTS OF SURGERY. 4,23 

flammation is moderate ; but, when it separates quickly, 
while the new bone is in a soft state, the detachment is 
always preceded by severe inflammatory symptoms, and 
followed by a temporary loss of the natural firmness of 
the limb. This premature separation of the sequestrum 
often occurs in necrosis of the lower jaw, and the chin 
consequently falls down on the neck. In certain cases, 
the sequestrum separates at each end from the living 
portions of the old bone, before the new osseous shell 
has acquired firmness, so that the limb feels as if it were 
broken in two places. 

" When the dead bone is removed by absorption, the 
process is tedious, and attended with a profuse discharge 
of matter, which gradually ceases, and at last stops al- 
together. In young subjects, this work is more quickly 
perfected, than in old ones. There are some chronic 
cases of necrosis, in which the sequestrum remains mi- 
absorbed, for an indefinite length of time, producing no 
violent irritation, yet, always enough to teazje the pa- 
tient, and disturb his health. 

"In necrosis of the long bones, there are always 
round apertures in the new osseous shell, corresponding 
with the external fistulous openings, so long as the se- 
questrum remains enclosed in it. 

"The tibia, femur, lower jaw, clavicle, humerus, 
fibula, radius, and ulna, are most frequently affected 
with necrosis. Excepting the lower jaw and scapula, 
the process of regeneration has only been noticed, in the 
cylindrical bones. From twelve to eighteen years of age 
is the time of life most subject to necrosis. The necro- 
gis of the lower jaw, however, seldom occurs before the 
age of thirty. In some persons, two bones are affected 
at once owing to constitutional causes. 

" The process of cure is said to take place with more 
celerity in the lower jaw, than any other bone, and may 



<f24 ELEMENTS OF SURGERY. 

be completed in three months. Mr. Russell has never 
known a necrosis of the tibia get well in less than a 
year ; but, in general, nearly two years elapse first ; some- 
times, the cure is protracted to a much greater length of 
time. 

" When the constitution is predisposed to necrosis, 
any cause, capable of exciting inflammation, may occa- 
sion an attack of it. Often, however, the disease is pure- 
ly sporadical, and not referrable to outward causes. 
Cases, which occur from external injury, are generally 
those of the lower jaw, which are frequently imputable 
to blows, the application of acrid substances to carious 
teeth, effects of mercury, &c. 

" Necrosis of the lower jaw and clavicle never proves 
fatal : that of the lower extremities, which is the worst 
case, does so very seldom, and only, from the violence 
of the first inflammatory symptoms, which rapidly bring 
on a hectic fever, which proves incurable without re- 
moving its local cause by a timely amputation. When 
the violence of the first stage, however, has abated, the 
irritation ceases, and the hectic symptoms, if there are 
any, are generally moderate. Nor is this state of tran- 
quillity disturbed, till the sequestrum, in making its way 
outward, again produces irritation. At this second pe- 
riod of urgency, extensive inflammation may originate, 
ulcerations spread all over the surface of the limb, as- 
sume an unhealthy appearance, violent fever succeed, 
and the patient either perish, or sink into a state, in 
which he must consent to amputation, as the only means 
of saving his life. This is the last crisis of imminent 
danger; but, in general it is less perilous, than when the 
inflammation comes on in an incipient stage of necro- 
sis.' 



: ; c » 



ti^MENTS OF SURGERY. 425 

TREATMENT. 

It may not be improper to remark in the first place 
that much may be done in preventing necrosis, and if 
the surgeon be called during the inflammatory stage of 
the disease which precedes the death of the bone, the 
antiphlogistic measures are to be vigorously employed. 
Bleeding, general and local, purging, and blisters will 
be found of great use, and there is reason to believe these 
remedies frequently successful in arresting the progress 
of the disoase. 

When the bone is actually dead it has already been 
stated that the actions of the adjacent parts are in general 
competent to the cure, but in many cases art is required. 

The means necessary to be pursued vary with the 
cases which occur ; when the dead portion is part of a 
broad flat bone, nothing is required but to wait for exfo- 
liation, which in general is accomplished without surgi- 
cal assistance. An inflammatory circle may be seen sur- 
rounding the dead portion, and after a time, a distinct 
fissure is formed and grows gradually wider, separating 
in every part of its circumference the dead from the liv- 
ing bone ; if only a superficial part of the bone have lost 
its life (either in a flat or a round bone) then the separa- 
tion proceeds underneath this plate, and it is gradually 
detached and loosened. It is useful in this stage of the 
process daily to move the loosened part as soon as it ad- 
mits of motion, but there is no necessity for taking away 
a part of it by means of a trephine, or by scraping it thin- 
ner, because the same natural process is required for re- 
moving a small as a large, a thin as a thick portion of 
bone, and precisely the same period of time will be re- 
quired for separating the one as the other, supposing 
their surfaces to be equal. Exfoliations from the skull 
afford frequent illustrations of these remarks. 

When any of the cylindrical bones are affected with 
VOL. ii. 3 l 



426 ELEMENTS OF SURGERY. 

necrosis through their whole extent, and the sequestrum 
is included in the new bone, it generally occasions so 
little inconvenience that it may be deemed bad surgery 
to interfere with the operations of nature. 

When the adjacent parts inflame, leeches and blisters 
should be applied, and the blisters should be dressed 
with savin ointment as recommended by Crowther. 

In some cases it becomes necessary to remove by a 
surgical operation the sequestrum. This is often a very 
painful, difficult, and hazardous operation. Supposing 
the affection seated in the thigh bone, nothing but neces- 
sity should induce the surgeon to lay bare and extract 
the dead bone before it becomes loose and approaches 
the surface.* In the tibia the operation is easier per- 
formed and oftener required. 

The circumstances which should induce the surgeon 
to perform the operation are, when great irritation is ex- 
perienced from the dead bone, — when it can be easily re- 
moved in consequence of its superficial or exposed si- 
tuation, — when the new bone incloses or overlaps it in 
such a way that a long period will probably be required 
for its removal, and when the articulating extremities of 
the bone are sound, for if these be diseased, amputation 
should be preferred to the extraction of the dead bone. 

OPERATION. 

This operation varies so much in different cases that 
general rules only can be given for performing it. 
The first stage of it consists in laying bare the affect- 
ed bone, and this should be done by cutting through 
the soft parts where they are thinnest, and where there 
is least danger of meeting with large blood-vessels, or 
other important parts. It is best to remove completely 

* The necessity alluded to is the extreme exhaustion and hectic state of the 
patient. 



ELEMENTS OF SURGERY. 4^7 

a portion of the integuments covering the hone by means 
of two curved incisions meeting at their extremities; a 
simple incision does not sufficiently expose the bone. Af- 
ter laying bare the new bone, a perforation is to be made 
through it with a trephine, and by means of this the se- 
questrum contained in it can be readily examined, and if 
small, can now be extracted. If this, however, cannot 
be done, the remainder of the operation consists in en- 
larging the opening by means of Hey's saw, or of chisels 
and gouges, until the dead bone can be removed. In 
general, it is best to perforate the lower part of the new 
bone, because a smaller aperture at an extremity will be 
sufficient, than at the middle of the bone. Perhaps the 
operation may in some cases be facilitated by breaking 
with strong forceps the sequestrum, when it is found too 
large to be conveniently extracted. After the dead bone 
is removed, the wound is to be dressed with dry lint, and 
treated as a common wound. 

Mr. Boyer is of opinion that very few cases occur 
which warrant the operation ; the British surgeons, on 
the contrary, often perform it. There can be no doubt 
that in many cases, great advantage must accrue from it, 
and whenever it is practicable, under the circumstances 
which have been mentioned, it ought to be performed. 
To ascertain in the clearest manner the propriety of an 
operation, Mr. Russell's mode of examining the parts 
may be adopted; it consists inlaying bare small portions 
of the bone in the vicinity of the fistulous openings, and 
if possible, introducing a probe into its cavity ; but if 
this cannot be done, a small hole may easily be drilled 
by means of a perforator, and through this the examina- 
tion may be made. If a large loose sequestrum be found, 
the operation of extracting it can be subsequently per- 
formed in the manner above directed. 



428 ELEMENTS OF SURGERY. 

CHAPTER LX. 

Of Setons and Issues. 

A seton is a wound kept in a suppurating state by 
means of a foreign matter which prevents its healing. 
The usual manner of making a seton is to pass a large 
flat needle nearly half an inch broad, through a folded 
portion of the skin. The needle is double-edged, and is 
armed with a skein of silk or thread dipped in sweet 
oil. The principal cautions necessary in forming a seton 
are in pinching up the fold of skin to avoid any other 
substance, and to be careful not to puncture any deeper 
seated part; and in the next place, to make the aper- 
tures through the skin sufficiently distant to prevent the 
thread from ulcerating through it. 

If no seton needle be at hand, the same end may be 
answered by puncturing a fold of skin with a common 
lancet, and then by means of an eyed probe, a skein of 
silk or thread can be passed through the wound. 

Setons may safely be made almost in any situation on 
the surface of the body. It is convenient to have one 
opening more dependent than the other, in order to fa- 
cilitate the discharge of pus. The skein of silk or thread 
should remain for a few days untouched until it becomes 
loosened by means of suppuration, after which that part 
of it which is nearest the wound is to be smeared with 
oil or ointment, and gently drawn into the suppurating 
canal. This process is to be repeated once or twice 
every twenty-four hours, and when the thread is nearly 
ail used, a fresh skein is to be attached to it. 

Great attention should be paid to cleanliness, espe- 



ELEMENTS OF SURGERY. 420 

cially in warm weather, and the silk or thread should be 
prevented from imbibing the pus which is discharged. 

It is easy when the matter does not flow in sufficient 
quantity to stimulate the wound by mixing cantharides 
with the oil or ointment smeared upon the thread. 

Issues are small ulcers artificially established for the 
purpose of procuring a discharge of pus. They form an 
important remedy in several diseases, and it is therefore 
of consequence to understand the best and easiest me- 
thods of making them. 

■* The situation in which the issue is to be formed is ge- 
nerally pointed out by the disease, but it is best to avoid 
placing them over a bone which is thinly covered, or 
over a considerable tendon, nerve, or blood-vessel, for 
very obvious reasons ; the belly of a muscle is also an un- 
favourable spot upon which to form an issue, because 
the motion of the part will occasion pain and inconve- 
nience. 

Among the most convenient situations for issues are 
the back part of the neck — the spaces along- side of 
the spinous processes of the vertebra — the arm at or near 
the insertion of the deltoid muscle — a hollow on each 
side of the knee above the flexor tendons of the leg. 

Various methods of forming issues have been con- 
trived. Among the simplest is the application of a small 
blister, which is to be dressed from time to time with 
epispastic ointment. This, however, is a plan which 
occasions a good deal of trouble to prevent the sore from 
healing, and the discharge is not in general sufficiently 
copious. 

Incisions are sometimes made through the skin, and 
into these incisions beans and peas are inserted to pre- 
vent the wound from cicatrizing. 

The use of caustic is however the best and most usual 
method of forming issues. The manner in which I have 



430 ELEMENTS OF SURGERY. 

been taught, and accustomed to apply it is as follows. 
A piece of leather is to be spread with adhesive plaster, 
and a hole is to be cut through this leather of the size 
and form of the intended issue. Another piece of leather 
is to be spread with the same plaster, in order to confine 
the caustic. The plaster first mentioned is to be warm- 
ed and applied to the skin in such a way that the hole 
cut through it may be on the part where the issue is to 
be made ; this hole is to be filled up with paste caustic 
and covered by adhesive plaster, to prevent it from fall- 
ing off. The paste caustic is made by mixing two parts 
of fresh burnt quick lime and one of common caustic 
(pure vegetable alkali) together, in powder, and forming 
them into a paste with a little soap, and a few drops of 
water. The caustic is to be left on until it destroys the 
skin, which will generally be found black and gangre- 
nous in an hour and a half or two hours, but if not, it 
must be reapplied and allowed to remain still longer. 
A poultice is afterwards to be applied, and in the course 
of a few days the eschar will separate from the sound 
parts. 

Dr. Wistar has contrived a method of forming issues 
which I think the most simple and least painful 1 have 
ever tried ; it consists in blistering with Spanish flies the 
surface of the skin, and rubbing for about ten minutes 
the blistered surface with common caustic. In this short 
space of time an issue is formed of the necessary depth. 
In order to make the issues of the proper shape, it is 
best to apply the Spanish flies to the skin in the same 
manner as the paste caustic is usually placed, in a hole 
cut out of a piece of leather spread with adhesive plas- 
ter. 

In order to keep an issue from healing it is necessary 
to press upon its surface beans, peas, or other foreign 
bodies, and occasionally to apply savin cerate, or Span- 



IF/NTS OF SURGERY. 431 

ish flies. I have often used a small block of hard wood 
with lozenges cut upon it ; the points of these lozenges 
bound upon the issue are more convenient of applica- 
tion than the beans or peas. To prevent the wood from 
imbibing moisture it may be coated with a solution of 
sealing wax in spirit of wine. 

Fungous granulations frequently arise from issues, 
and grow to a very considerable height ; when this hap- 
pens, the application of lunar caustic should be made 
and repeated as often as may become necessary, and the 
future growth of these granulations may be prevented by 
dressing the issue occasionally with escharotics, as burnt 
alum, or red precipitate. 

Issues should be washed twice in twenty-four hours 
with warm water ; if cleanliness be neglected they become 
extremely offensive. 



43g ELEMENTS OF SURGERY. 

CHAPTER LXI. 

Of Mal-formations. 

To enumerate all the deformities found in new born 
infants would require many chapters. The records of 
medicine, especially those written in more credulous 
ages, are replete with monstrosities in every form. The 
writings of Ambrose Pare exhibit a motley group of these 
prodigies. 

On the present occasion it will only be necessary to 
speak of those deformities which are of frequent occur- 
rence or which can be remedied by art. 

OF HARE-LIP. 

Fissures in the upper lip of infants extending in many 
cases through the roof of the mouth, affecting the bone 
as well as the soft parts, have received from the resem- 
blance to the mouth of the hare, the appellation of hare- 
lip. In some cases the fissure is in the middle of the 
lip ; more generally it is on one side, and occasionally 
there is a double hare-lip, a fissure existing on each 
side. 

Its extent varies considerably ; sometimes it is confined 
to the edge of the lip, at other times it extends up to the 
nose and even into the nostril; sometimes, the lip alone, 
is affected, in other cases the gum, and superior maxil- 
lary bone are divided, and the fissure extends even 
through the roof of the mouth completely to the soft pa- 
late, the nostril and mouth forming one cavity. The 
velum pendulum palati is sometimes divided. 

The deformity, if no other inconvenience existed. 



ELEMENTS OF SURGERY. <|33 

would be a sufficient motive for the performance of any 
operation necessary to effect its removal, but in addition 
to this, the child sucks and swallows with great difficul- 
ty, and if a cure be not effected will remain unable to 
articulate distinctly. 

It is the custom to postpone the operation for hare-lip 
till the infant advances to the age of two years and up- 
wards, under an idea that convulsions will result from 
it — this caution is I believe superfluous, and the earlier 
the operation is performed, the more complete will be 
its beneficial consequences especially in those easel 
where the bones are affected, because in very early life 
the vacuity will be more perfectly filled up. 

The operation for the cure of hare- lip consists in par- 
ing off the epithelium and skin of the lip, on each sid6 
of the fissure, and keeping the cut surfaces in contact by 
means of the twisted suture. We are directed in the 
more modern surgical authors, to perform the operation 
with a sharp scalpel, from a fear that the contused wound 
occasioned by scissors will not unite by the first inten- 
tion, this caution, proceeding from an unnecessary re- 
finement upon the doctrines of adhesion is totally use- 
less, the operation may with great facility be performed 
by scissors, and the wound heals in every instance by 
the first intention, provided the suture is properly ap- 
plied. 

It is of great consequence whether the knife or scis- 
sors be employed, to cut out the upper angle of the fis- 
sure, that the piece removed shall form the letter V, if 
this be not attended to, the whole of the surfaces will 
not unite. 

When the skin of the lip is removed, the wound re- 
sembles any other incision through the same part, and 
the mode of treatment must be similar to that employed 

vol, ii. 3 K 



434 ELEMENTS OF SURGERV. 

in wounds through the lip. Two silver pins with move ■ 
able steel points are to be passed into the lip half an inch 
from the wound, these pins are to be pushed through the 
substance of the lip in such a manner as to pass through 
the wound ; they should not extend deeper than two- 
thirds through the substance of the lip, the points are to 
be brought out half an inch from the wound on the op- 
posite side, and then removed ; a firm ligature of waxed 
thread is now to be passed round and round these pins 
in the form of the figure 8, in such a manner as to con- 
fine the sides of the wound in contact, (see plate I.) In this 
manner the twisted suture is formed, and it certainly is 
more convenient and effectual than the interrupted suture 
in this particular instance, although the latter is preferred 
by some surgeons, and no doubt answers tolerably well. 

When the operation for hare-lip is deferred until the 
teeth have grown, we often find the large incisors pro- 
jecting on the edges of the fissure in the upper maxillary 
bone, they should be removed in such cases before the 
operation is performed. 

In double hare-lip the same method of removing the 
skin is to be performed on both sides, but the number of 
pins need not be increased in this case, they must pass 
through the insulated central portion of the lip, and great 
care is necessary in the accurate co-aptation of the 
wounded surfaces. The pins should in general be taken 
out at the end of the fourth day from the operation. 

When the lower lip is totally or partially affected 
with cancer, its removal becomes necessary ; in these cases 
an incision is to be made on each side of the diseas- 
ed part with a bistoury or scalpel, and the lip dissected 
loose from the lower jaw ; if practicable the incisions 
should meet in a point at the chin, or on one side of it, 
and then the sides of the wound can be closed by the 



ELEMENTS OF SURGERY. 435 

twisted suture, the pins being introduced and the liga- 
ture applied, just as in cases of hare-lip, if even the 
whole lip is extirpated the deformity is by no means 
very great. The bleeding, in operations both on the 
upper and under lip, is generally profuse at first, but 
soon ceases. Cancer of the upper lip is to be extirpated 
and treated when practicable in the same manner. 



436 ELEMENTS OF SURGERV, 

CHAPTER LXII. 

Of Club Foot. 

It is a matter of some surprise to all intelligent mem 
that the treatment of distorted limbs has excited so little 
the attention of surgeons. In consequence of this neglect, 
the management of such cases generally falls into the 
hands of empirics, or nurses, and if this class of persons 
are warrantable for their interference in any complaints 
it is in these, because the cure consists in mechanical 
contrivances which cannot affect life, and which are often 
highly serviceable. 

It is evident at the first view of such a subject, that 
distortions of the feet must vary greatly in their nature 
and degree, and consequently require very different treat- 
ment. The most usual form of the complaint, however, 
consists in a turning inward and upward of the sole of 
the foot, in the manner represented in the opposite out- 
lines ; when a person with such a foot begins to walk, 
he walks on the outer edge of the foot, and the deformity 
gradually increasing, the upper part of the foot becomes 
the lower, and he walks upon the top or iustep instead of 
the sole. 

The relative position of the bones of the tarsus to 
those of the leg is altered in club foot, and constitutes 
one derangement of the parts. The bones of the tarsus 
are themselves unnaturally formed, and this constitutes 
a second deformity. The action of the muscles upon 
parts changed from their natural form will tend very ma- 
terially to augment the deformity, and consequently the 
longer they are suffered to act, the greater this deformity 
will be. 



dub Foot. 





A Sctltp 






u 



ELEMENTS OF SURGERY. 43f 

The causes of club foot are not very easily ascertain- 
ed ; what effect pressure on the foetus in utero may have 
I am not prepared to decide. 

The indication of cure in club foot is to effect by ar- 
tificial means a change from the unnatural to a more 
natural posture of the foot, and this is to be attempted by 
splints and bandages accommodated to the particular na- 
ture of each case. 

It is of great importance to commence the treatment of 
club foot as soon as possible after birth. The bones are 
not at this time completely formed, and are susceptible 
of any change in shape which circumstances may direct. 
The muscles have not yet acted sufficiently to augment 
the original derangement. We are not, however, to be de- 
terred from endeavours to relieve the complaint even 
when years have elapsed before surgical aid is request- 
ed, for great benefit has been derived in many cases 
from the use of the necessary machinery even after the 
age of puberty. 

To effect a change in the shape of the foot, permanent 
pressure must be applied in such a manner as to separate 
those parts where bony matter is deficient, and to force 
together those in which it is .redundant; this will be in 
fact to bring the foot as nearly as possible to its natural 
form. 

Mr. Sheldrake, an ingenious instrument maker of Lon- 
don, who has acquired much celebrity by his skill in the 
treatment of club foot, has very correctly stated the man- 
ner in which pressure acts in restoring the natural form. 

" If so much pressure is applied as to bring the sepa- 
rated parts of those bones into contact, and is invariably 
supported, it will stop the growth of that gelatinous sub- 
stance, which is first formed in those parts where the 
bones come in contact with each other ; in those parts 
which do not come in contact, it will continue to grow 



438 ELEMENTS OF SURGERY. 

till they meet ; the progress of ossification will be con- 
tinued, in the natural way, till the patient arrives at ma- 
turity ; and with no more mal-formation than existed at 
the time the pressure was first applied. 

" If more pressure is applied and uniformly kept up, 
the cartilages will be compressed in those parts in which 
they come in contact ; and if only the natural action of the 
foot is permitted, will assume a permanent form, as near- 
ly approaching to the natural one, as the pre-existing de- 
formity will admit. This compression of the cartilages 
will, by condensing their substance, prevent the arteries 
from shooting so freely into it, in an improper direction, 
as they would have done but for this impediment, and 
thus stop the progress of ossification in an improper di- 
rection, while that process will go on in the natural way, 
in every other part, till the patient has arrived at ma- 
turity, and every part is completely formed. 

u If the same pressure is uniformly continued, or a 
greater degree of pressure be constantly applied, the ac- 
tion of the arteries, which deposit the earthy particles 
nearest the surface of the bones, will likewise be imped- 
ed, while the action of the absorbents, which, in the 
course of circulation, are employed in taking up earthy 
particles, will be continued in full vigour, if it is not in- 
creased ; and by perseverance in this process it is cer- 
tainly possible, that an unequal action, i. e. a diminished 
action of the secreting vessels, and an increased action of 
the absorbiug vessels, may be kept up, and so modified, 
as to alter the form of these bones, long after they are 
ossified ; and, of course, so much of the deformity of 
such feet as depends on mal-formation of the bones, may 
be radically cured, long after that period of life at which 
they have generally been thought incurable." 

When the deformity consists in a curvature at the all- 
ele joint, and another in the foot, which is the case in a 



ELEMENTS OF SURGERY. 439 

majority of instances, a great deficiency of bone appears 
in the inside of the foot, as much as if one of the cunei- 
form bones were completely absent, and a proportionate 
surplus of bone exists on the outside. In such cases Dr. 
Physick has succeeded in removing every vestige of de- 
formity by a contrivance which is represented in the an- 
nexed plate. 

From the uniform success which resulted from the ap- 
plication of this apparatus, I have used it, and known it 
used in a great number of instances, and I recommend it 
in preference to every other machine ; modified accord- 
ing to circumstances, I believe in applicable to every case 
of club foot which is met with in practice. 

I lament that' I have not been able to procure a trea- 
tise on club foot which has recently been published by 
Professor Scarpa, as I have no doubt his industry and 
zeal must have thrown light on this, as on the other sub- 
jects of which helms treated. 



^•a— ~ 



410 ELEMENTS OF SUKGER\. 



EXPLANATION OF THE PLATE. 



a. b. A shoe made of sheet tin covered with leather. 

a. a. The sole. 

b. A projecting plate of tin soldered to the sole, by which 

lateral pressure is made on the inner edge of the foot 
at b, and on the outer edge of the heel at c. 

d. A strap passing over the top of the foot and secured 
to the buckle e on the opposite side. The object of 
this strap is to compress (he upper part of the foot, 
and to bring the sole gradually in contact with the 
sole of the shoe. It should always be drawn tight 
enough to prevent the foot from turning. 

/. A steel splint passing up the leg to counteract the ten- 
dency of the ankle joint to turn inwards ; the joint 
g, allows some degree of extension and flexion to 
the foot. 

h. h. A plate of thin brass, iron, or tin, passing round 
the leg. This plate as well as the steel splint are 
covered with soft buckskin, which laces in front, 
but which to prevent confusion is omitted in the 
drawing. 
The instrument here represented is adapted to the left 

foot of a new born infant. A larger one must be used for 

an older child. 



Plate xsvn 




ELEMENTS OF SURGERY. 441 

CHAPTER LXIIL 

Of Spina Bifida. 

This consists in an imperfect state of one or more of 
the vertebra, and a swelling containing a fluid at the 
spot where the imperfection exists. 

The tumour is generally found at one of the lumbar 
vertebrae ; sometimes on the os sacrum ; aud occasionally 
at one of the cervical or dorsal vertebrae. A tumour ana- 
logous to this occurs on the heads of children, and is called 
by the same name. The swelling in every case appears to 
result from imperfect ossification, or a congenital defi- 
ciency of some part of the cranium or spine. 

Children affected with spina bifida seldom live long. 
Warner relates an instance in which the patient lived to 
the age of twenty, but in general they survive a very few 
years. 

The fluid contained in the tumour is commonly a lim- 
pid colourless serum, but sometimes it has been found 
turbid and tinged with blood. In examining spina bifida, 
a fluctuation can always be felt, and in general the defi- 
ciency of bone can be discovered by the finger ; this defi- 
ciency is usually between two of the spinous processes, 
though sometimes one spinous process is entirely want- 
ing; a membrane, supposed to be a continuation of the 
dura mater, invests the fluid, and forms a kind of cyst 
around it, adhering closely to the external integuments. 

Paralysis of the lower limbs sometimes attends £ie 
compMpt, but not uniformly. 

No remedy has hitherto been discovered for this com- 
plaint; and it has not, so far as I have learned, in a sin- 
gle instance been cured. The tumour has been opened 
by caustic and by incision, always with a fatal result. 

VOL. II. 3 L 



44^ ELEMENTS OF SURGERY. 

Mr. Abernethy has proposed to compress the tumour 
gradually from its commencement, with a view to effect 
the absorption of the fluid, and to prevent the distension 
of the unsupported dura mater. He also suggests the pro- 
priety, if this should fail, of puncturing the tumour with 
a finely cutting instrument, the wound to be immediately 
after closed with sticking plaster, and healed : the reac- 
cumulation of the fluid he proposes to prevent by local 
pressure. In one case Mr. Abernethy punctured a spina 
bifida every fourth day for six weeks, during which time 
the child's health continued unaffected, and the wounds 
healed. The plaster, however, was rubbed off from one 
of the punctures, and the part ulcerated ; the opening 
could not be healed, and death ensued : the discharge 
being previously changed from serum to a purulent fluid. 

Mr. Benjamin Bell proposed to tie a ligature firmly 
upon the tumour, a practice in no respect adapted to the 
$ase, and Richter's proposal of issues is as little likely 
to be serviceable ; so that a remedy for spina bifida is 
still to be considered a desideratum. 

Spina bifida is occasionally accompanied by hydroce- 
phalus. A rupture of the tumour in such a case has oc- 
casioned a diminution of the size of the patient's head, 
and discharged the fluid contained in it. I have evacu- 
ated the water of a hydrocephalus through a flattened 
trochar in a child several times, with the effect relieving 
the symptoms, but death resulted. Upon dissection I 
found that my operation had been a very safe one, for 
the whole brain was compressed in such a way as to 
fo^n a lining for the dura mater scarce half an inch thick, 
its blood-vessels were very small, and the punctnps had 
healed up. Whether Mr. Abernethy's operation on the 
spina bifida would be more successful I very much doubt, 
it is however warrantable, — "anceps remedium potius 
quam nullum." 



ELEMENTS OP SURGERY, 443 

Mr. Astley Cooper has published some cases which I 
^hall here insert as proofs, that this disease is no longer 
to be considered as utterly beyond the reach of surgery. 

" James Applebee, Baldwin Street, Old Street, was 
born on the 19th of May, 1807, and his mother, imme- 
diately after his birth, observed a round and transparent 
tumour on the loins, of the size of a large walnut. 

"Mr. Deering, who was her accoucheur, requested 
Dr. Petch to see the child with him, who informed the 
mother of the dangerous nature of the complaint, and of 
the probability of its fatal termination. 

" On the 2M of June, 1807? the child was brought to 
my house, and I found, that although it had spina bifida, 
the head was not unusually large ; that the motions of 
its legs were perfect ; and its stools and uriue were dis- 
charged naturally. 

" I applied a roller around the child's waist, so as to 
compress the tumour, being induced to do so from consi- 
dering it as a species of hernia, and that the deficiency of 
the spine might be compensated for by external pressui^k 

"The pressure, made by the roller, had no unpleasanr^ 
influence on its voluntary powers ; its stools and urine 
continued to be properly discharged, but the mother 
thought, that the child was occasionally convulsed. 

" At the end of a week, a piece of plaster of paris, 
somewhat hollowed, and that hollow partly filled with a 
piece of lint, was placed upon the surface of the tumour: 
a stra|) of adhesive plaster was applied to prevent its 
changing its situation, and a roller was carried around 
the waist, to bind the plaster of paris firmly upon the 
back, And to compress the tumour as much as the child 
could bear. 

" This treatment was continued until the month of 
October, during which time, the tumour was examined 



444 ELEMENTS OF SURGERY. 

about three times a week, and the mother reported, that 
the child was occasionally convulsed. 

" When the child was five months old, a truss was ap- 
plied, similar in form to that, which I sometimes use for 
umbilical hernia in children, and this has been continued 
ever since. 

u At the age of fifteen months, it began to make use of 
its limbs; it could crawl along a passage, and up two 
pair of stairs. 

(( At eighteen months, by some accident, the truss 
slipped from the tumour, which had become of the size 
of a small orange, and the mother observed, when it was 
reduced, that the child appeared in some degree dull ; 
and this was always the case, if the truss was left off for 
a few minutes, and then re-applied. 

" At fifteen months, he began to talk ; and at two years 
of age, he could walk alone. 

" He now goes to school, runs, jumps, and plays about, 
as other children. His powers of mind do not appear to 
differ from those of other children. His memory is reten- 
^e, and he learns with facility. He had the measles and 
small-pox in the first year, and the hooping cough at 
three years. His head, previously and subsequently to 
the bones closing, has preserved a proper proportion to 
the other parts of the body. 

" The tumour is kept by the truss entirely within the 
channel of the spine ; but, when the truss is removed, it 
soon becomes of the size of half a small orange./ It is 
therefore necessary, that the use of the truss should be 
continued. When the truss is removed, the finger can be 
readily pressed through the tumour into the channel of 
the spine." (Medico Cldrurgical Transactions^Vol. 2. 
p. 323, $c.) 

The next case, also published by Mr. Astley Cooper, 



ELCMBNT9 OF SURGERY. 415 

will prove, that spina bifida may sometimes be treated 
on another plan, so as to accomplish a permanent cure. 

"January 21st, 1809, Mrs. Little, of No. 27, Lime- 
house Causeway, brought to my house her son, aged ten 
weeks, who was the subject of spina bifida. 

" The tumour was situated on the loins; it was soft, 
elastic, and transparent ; and its size about as large as a 
billiard-ball when cut in half; his legs were perfectly 
sensible, and his urine and feces were under the power 
of the will, &c. 

" Having endeavoured to push the w ater, contained in 
the tumour, into the channel of the spine, and finding 
that if the whole was returned, the pressure would be too 
great upon the brain ; I thought it a fair opportunity of 
trying what would be the effect of evacuating the swell- 
ing by means of a very fine pointed instrument, and by 
subsequent pressure to bring it into the state of the spina 
bifida in Applebee's child. 

u I therefore immediately punctured the tumour with a 
needle, and drew oflf about two ounces of water. 

" On the 25th of January, finding the tumour" as large 
as before it had been punctured, I opened it again, and in 
the same manner, and discharged about four ounces of 
fluid. The child cried when the fluid was evacuated, but 
not whilst it was passing off. 

ik On January 28th, the tumour was as large as at first, 
I opened it again, and discharged the fluid. A roller was 
applied over the tumour, and around the abdomen. 

" February 1st, it was again pricked, and two ounces 
of fluid discharged. 

" On the 4th, three ounces of fluid were discharged. 

" On February 9th, the same quantity of fluid was 
evacuated as on the 4th ; but, instead of its being perfect- 
ly clear, as at first, it was now sanious, and it had been 
gradually becoming so in the three former operations. 



446 ELEMENTS OF SURGEKY. 

"On the 43th, the same quantity of fluid was taken 
away ; a flannel roller was applied over the tumour and 
around the abdomen ; a piece of pasteboard was placed 
upon the flannel roller over the tumour, and another roller 
over the pasteboard to confine it. 

" On the 17th, three ounces of fluid, of a more limpid 
kind, were discharged; the pasteboard was again ap- 
plied. 

" On the 27th, the surface of the tumour inflamed ; 
the fluid, not more than half its former quantity, wa9 
mixed with coagulable lymph, and the child, suffering 
considerable constitutional irritation, was ordered calo- 
mel and scammony, and the rollers were discontinued. 

" February 26th, the tumour was not more than a 
quarter of its former size ; it felt solid ; the integuments 
were thickened, and it had all the appearance of having 
undergone the adhesive inflammation. 

" On the 28th, it was still more reduced in size, and 
felt solid. 

" On March 4th, it was in the same state as on the 
28th of February. 

" March 8th, the swelling was very much lessened ; 
the skin over it thickened and wrinkled ; a roller was 
again had recourse to ; a card was put over the tumour ; 
and a second roller was applied. 

" March 11th, the tumour was much reduced ; the skin 
covering it was a little ulcerated. On the 15th, it was 
flat, but still a little ulcerated. 

" On the 27th, the effused coagulable lymph was con- 
siderably reduced in quantity, and of a very firm con- 
sistence. 

" On the 2d of May, nothing more than a loose pen- 
dulous bag of skin remained, and the child appearing 
to be perfectly well, the bandage was soon left off. 



ELEMENTS OF SUKGEItY. 447 

" On December 18th, it was attacked with the small- 
pox, and went well through the disease. 

" The skin now hangs flaccid from the basis of the sa- 
crum ; its centre is drawn to the spine, to which it is 
united, and thus the appearance of a navel is produced 
in the tumour by retraction of the skin. 

" The pricks of the needles are very obvious on each 
of the punctured parts of the tumour, forming slight in- 
dentations. " (See Medico- Chirurgical Transactions, 
Vol.2, p. 326—329.) 



448 ELEMENTS OF SURGERY. 

CHAPTER LXIV. 

Of Imperforate Anus. 

Mr. Benjamin Bell has published in his system of 
surgery a very good account of this subject ; from that 
work I shall offer the following extract. 

(i Although an imperforated anus is not a frequent oc- 
currence, yet as it is occasionally met with, and as it is of 
much importance to have such deficiencies soon disco- 
vered, every midwife ought to examine with attention 
the state of all the natural passages as soon as possible 
after delivery. 

" In some cases of this nature, the end of the rectum is 
found to be somewhat prominent at the usual situation of 
the anus, and to be only covered with skin and a small 
quantity of cellular membrane : but in others, no vestige 
of the rectum can be perceived ; and the skin retains its 
natural appearance, without being any where elevated be- 
twixt the scrotum and the pojnt of the coccyx. 

" In some of these, the rectum has been found to ter- 
minate within an inch of the ordinary seat of the anus ; 
in others it has reached no further than the top of the sa- 
crum. In some it has been known to terminate in the 
bladder ; and in others, in the vagina. 

(i When the assistance of an operator is required in 
such cases, as death is in all probability to be the conse- 
quence if a proper vent be not obtained for the faeces, no 
time should be lost in deliberation. — If the end of the 
gut is found to be covered with skin merely, and if a 
protuberance is formed by the faeces pushing it forward, 
all that a surgeon has to do, is with a scalpel or lancet 
to make an opening sufficient for evacuating them 5 but 



ELEMENTS OF SURGERY. 449 

when no direction of this kind is met with, the case 
comes to be much more complicated, and more difficulty 
and danger are accordingly to be expected. 

" In such cases where the gut is found to lie deep, on 
the child being properly secured, an incision of an inch 
in length should be made directly on the spot where the 
anus ought to be : and this should be continued by gra- 
dual and repeated strokes of the scalpel, in the direction 
the rectum is usually known to take ; not in a direct 
course through the axis of the pelvis, for in that direction 
the vagina or bladden, or perhaps both, might be brought 
to suffer ; but backwards ajong the coccyx, where there 
is no risk of wounding any part of importance. The 
best director in every case of this kind, is the finger of 
fie operator. The fore-finger of one hand being pushed 
in towards the coccyx, the surgeon with the scalpel in the 
other, should dissect gradually in this direction, either till 
he meets with faeces, or till the scalpel has reached at least 
the full length of his finger; and if, after all, the faeces 
are not evacuated, as death must undoubtedly ensue if 
something further be not attempted, a long trochar should 
be pushed forward upon the finger, in such a direction as 
the operator thinks will most probably meet with the gut. 
" In this manner many lives have been saved which 
would otherwise have been lost. I myself have had two 
such cases ; in both of which the gut lay deep, and in both 
I was fortunate enough to form an anus, which for a good 
many years has continued to answer the purpose suffi- 
ciently. But in each of these a great deal of difficulty 
was experienced in preserving the passage sufficiently 
wide and open ; for as soon as the dossils of lint and 
other tents made use of for preserving the passage were 
withdrawn, such a contraction occurred as for a conside- 
rable time reudered the evacuation of the feces extremely 
difficult. Sponge tent, gentian root, and other substances 

VOL. II. 3M 



450 ELEMENTS OF SURGERY. 

which sWell by moisture, were at different times employ- 
ed; but these were uniformly found to produce so much 
pain and irritation as rendered their continuance altogether 
inadmissible : applications of this kind are frequently, in- 
deed recommended in such cases; but any person who 
has ever used them in parts so exquisitely sensible as the 
rectum always is, will readily acknowledge the impro- 
priety of the advice. 

" Dossils of soft lint moistened in oil, and rolls of bou- 
gie plaster of a proper size, were found to irritate less 
than any other application ; and for the purpose of dilat- 
ing the passage, when, at different times during the cure, 
it was found to have become too strait, the method we 
have already had occasion to mention, of compressing 
blood-vessels in the rectum by introducing a sheep's gut 
shut at one end, into it, and forcing water into it by the 
other, was also found to answer here. But, upon the 
whole, although this part of the cure may appear to those 
who have not met with such cases, to be a simple and 
easy matter, it is found to be much otherwise in practice. 
Indeed, no case I was ever concerned in afforded so 
much trouble and perplexity as was experienced from 
each of those I have mentioned; for although in both, 
the openings were at first made sufficiently large, yet 
nothing but a continued attention for the space of eight 
or ten months prevented the necessity of a frequent repe- 
tition of the operation. When the skin alone is to be 
cut, it is a very simple matter indeed ; for in this case 
nothing in general is necessary but the introduction of a 
dossil of soft lint for a few days into the opening made 
by the scalpel. But when the rectum lies very deep, I 
am inclined to think, from the event of these cases al- 
luded to, that although, ultimately, a complete cure may 
commonly be obtained after a free discharge of faeces is 
procured, that much nicety and attention on the part of 



ELEMENTS OF SURGERY. ^\ 

the operator will always be required for a considerable 
time after the operation ; and in general we may suppose, 
that the difficulty will be in proportion to the depth of the 
cut. 

"Even where the gut is found to terminate in the blad- 
der or in the vagina, the operation we have recommended 
should be undoubtedly practised : for, in the former case, 
as all the faeees must be emptied into the bladder, much 
risk must occur of such accumulations being formed as 
may put a total stop to the discharge by the urethra ; and 
in the latter, where the rectum terminates in the vagina, 
much inconvenience and distress must be incurred ; which, 
if the operation succeeds, may possibly be prevented. 
There cannot indeed be any certainty of the operation in 
question proving altogether effectual in obviating the in- 
conveniences produced by the gut terminating in the blad- 
der or vagina, as there must still be a probability of part 
of the faeces continuing to pass off by these outlets ; but 
as a free passage procured in this manner, affords at 
least a tolerable chance of relief, no doubt ought to be 
entertained of putting it in practice. 

"When it unfortunately happens that no passage is ob- 
tained for the faeces by any of the means we have pointed 
out, might not we attempt an opening above the pubes, 
or perhaps ou the right side so as to reach the caput coli, 
with a view of making an artificial anus in one or other 
of these places ? It is true, the chance of success from 
such a measure would not be great; and, even allowing 
the attempt to succeed in the most complete manner, the 
discharge of faeces from such openings would always prove 
troublesome and uncomfortable : but the melancholy idea 
of leaving a child in such a situation, to die in much 
pain, must prove so highly distressing, both to the friends 
and the operator, as would at anytime rather incline one 



45S ELEMENTS OF SURGERY. 

to have recourse even to the doubtful and desperate re- 
medy we have mentioned." (B. Bell.) 

A very interesting case of imperforate anus is related 
by my friend Dr. J. A. Smith, in the second volume of 
the New York Medical and Philosophical Journal ; in 
that case the rectum communicated with the urethra, 
through which canal its contents were evacuated. An 
unsuccessful operation was performed for the relief of 
the patient, the wound healed, but within a month the 
child expired, and no dissection being permitted, the 
mode and place of communication between the rectum 
and urethra or bladder remained unknown. 

Mr. BelFs proposal to cut into the caput coli, or to 
make an opening above the pubes, is one which has 
never been put in practice, and probably never will be 
by any prudent practitioner. 



KLEMKNTS OF SUHGKK\ 453 

CHAPTER LXV. 

. Of Imperforate Vagina, 

It is by no means unusual to find in new born girlsj 
that the vagina is imperforate. Sometimes the passage 
is closed by an obstruction higher up than the meatus 
urinarius, and in that case the bladder evacuates itself 
as usual, and the imperfection remains for a time undis- 
covered ; sometimes even until after marriage when 9 
surgical operation is found indispensable. 

In general the vagina in such cases is closed by a 
membrane, which is nothing more than the hymen but 
is unusually dense and strong; if an aperture exist in it 
through which the menses can flow, surgical aid will not 
often be required, but if it be entirely closed a great deal 
of suffering is experienced by the patient when the cata- 
menia commence, and death has even resulted before the 
nature of the complaint has been made known. 

When the vagina is closed by a membrane, the ope- 
ration by which it is to be relieved is extremely simple. 
A straight incision, or if the membrane be very dense, a 
crucial incision should be made through it, and the 
wound kept from uniting by the introduction of a sponge 
tent, or roll of linen. Cases are recorded in which pro- 
digious quantities of black putrid blood have been dis- 
charged by such an operation, and the lives of many pa- 
tients have been saved by this simple process. 

A more difficult operation becomes necessary when in- 
stead of a mere membrane to be divided, the surgeon 
finds an obliteration of the vagina, or a concretion of its 
sides. In this case he must proceed by slow and cau- 
tious dissection, guarding with extreme care the bladder, 



454 ELEMENTS OF SURGERY. 

on the one side and the rectum on the other. De Haeu 
relates a case in which the bladder was actually opened 
and death resulted. 

The vagina often becomes obliterated by adhesions, 
in consequence of inflammation from disease or violence. 
I have known this to happen from an injury received in 
parturition, and I have had a patient under my care in 
whom it resulted from a disease of the uterus. In such 
cases if they occur in early life, and the menses collect, 
an aperture must be made for their evacuation. 

Dr. Physick has once been called upon to dissect a 
•passage to the uterus, in a case where the vagina was 
entirely closed up to a considerable distance within the 
os externum. After a cautious dissection through a very 
considerable thickness of parts, the operation was accom- 
plished, and the vagina was kept open and dilated by the 
use of tents. 



ELEMENTS OF SURGERY 4^5 

CHAPTER LXVI. 

Of the Ccesarian Operation. 

The extraction of a foetus from the uterus by means of 
an incision through the parietes of the abdomen has long 
been known by the name of the Caesarian section. 

The operation is said to be necessary, first, when the 
foetus is alive and the mother has died in labour, or dur- 
ing the two last months of pregnancy ; secondly, when 
the foetus is dead, but cannot be expelled in the usual 
manner, in consequence of deformity in the mother, or of 
the inordinate size of the child ; and thirdly, when both 
mother and child are living, and the causes last men- 
tioned prevent delivery. As the discussion of the causes 
which may demand the operation would involve a varie- 
ty of considerations not properly belonging to a surgical 
treatise, I shall refer to the writers on midwifery for an 
account of them, and on, tj^is question shall simply state 
that there are some cases in which no doubt can exist as 
to the propriety of extracting a foetus by an external in- 
cision, the use of the crotchet, however, has greatly 
lessened the necessity of the operation, and I wish by no 
means to be understood as recommending it except in cases 
where in the opinion of a skilful accoucheur the death 
of the mother is the only alternative, or where after the 
death of the mother there may be reason to suppose the 
child alive. 

In cases of extra-uterine conception, it is sometimes ne- 
cessary when the foetus is situated in one of the ovaries, 
or fallopian tubes, or within the cavity of the peritoneum, 
it is impossible for it to be delivered in the usual manner. 
In these cases I believe the best practice is to wait until 



4.5G ELEMENTS OF SURGERY. 

the formation of an abscess takes place, an event which 
may reasonably be expected. The putrid foetus will 
then be evacuated either through the rectum, or through 
the external parietes ; many instances have occurred in 
which these terminations have taken place, and the 
mother has happily survived. I received some time 
since from my friend Dr. Vaughan, of Virginia, the bones 
of a foetus evacuated through the rectum, the mother hav- 
ing completely recovered. 

Should suppuration, however, take place, and the ab- 
scess break externally without a sufficient opening for 
evacuating the foetus, the aperture may be enlarged by 
the knife, to facilitate this process. Such a case occur- 
red recently in New York. Dr. J. A. Smith has de- 
tailed it in the first volume of the Medical and Philo- 
sophical Journal. 

In this case, Dr. Smith remarks, "there were two 
small orifices through which the matter made its way, 
one somewhat above, the other directly at the umbilicus. 
Upon introducing a probe into the latter, bone could be. 
felt at no great depth. As the patient was rapidly sink- 
ing under hectic fever and diarrhoea, it was decided that 
a speedy performance of an operation was the only 
means of saving her life. Having first introduced a probe 
into the sac, I made an incision at the inner edge of the 
right rectus abdominis muscle, from an inch and a halt' 
above to the same distance below the umbilicus. At 
three strokes of the knife I got into the sac, and intro- 
ducing ray finger dilated upwards and downwards as far 
as could be done with safety, for had I gone beyond the 
adbesion of the sac to the parietes of the abdomen and 
thus exposed the cavity of the peritoneum, the patient 
must have died. I then proceeded to extract the bones 
with my dressing forceps conducted by my finger, which 
at first was easily done, but after removing two or three 



ELEMENTS OF SLRGERY. 457 

it became more and more difficult, and at last I found it 
absolutely impracticable to get away any more, at least 
without doing a violence to the woman which she could 
not possibly survive. This disappointment arose from 
a circumstance which it was impossible to foresee, for 
from the length of time which had elapsed from the death 
of the foetus and other circumstances, we had every rea- 
son to suppose that all the soft parts of it were destroyed 
by putrefaction, but as this unfortunately had not hap- 
pened I was obliged to desist. This I did the more wil- 
lingly as I was convinced if the patient did not die of 
symptomatic fever that the putrefactive process would go 
on much more rapidly, and that the bones might be taken 
away as they became detached. The event justified my 
expectation. The wound was filled with lint, and the 
patient put to bed. She lost an inconsiderable quantity 
of blood during the operation, and subsequently recover- 
ed, the whole foetus being removed from the wound within 
a few days." 

An instance is recorded of a living foetus cut out at the 
groin. But these are not genuine cases of the Caisarian 

operation. 

As the operation of opening the uterus through the ab- 
domen may become necessary from invincible obstacles 
to the extraction of the foetus, either in a living or dead 
state, I shall describe in this place the manner of per- 
forming it; it should certainly be done before both 
mother and child have perished from the violence of the 
pains, flooding, convulsions, &c. 

The operation being determined upon in a case of 
uterine conception, the patient is to be placed upon a 
table of the usual height and laid upon her back, her 
head moderately elevated, and her thighs somewhat 
raised, in order to relax the muscles of the abdomen ; au 

vol. ii. 3 N 



458 ELEMENTS OF SURGERY. 

incision is then to be made six inches long through the 
skin and cellular substance. In my opinion this incision 
should be in the course of the linea alba, because no mus- 
cular fibres will be here divided, and there will be less 
probability of wounding an intestine : (an exception 
however, to this direction will be presently mentioned.) 
After the linea alba is exposed, an opening should be 
made through it just below the umbilicus. A probe- 
pointed curved bistoury is now to be introduced, and 
with it the incision through the tendon and periosteum is 
to be enlarged to the size of the external incision, great 
care being taken not to wound any of the intestines. 
The uterus is next to be opened by an incision of the 
same length as the first, and through this the foetus is to 
be extracted, and afterwards the placenta and mem- 
branes. A case is described by Mr. Artiste in the Edin- 
burgh Surgical Journal, in which the operation per- 
formed in this manner was completely successful, and 
both mother and child were preserved. 

The cases in which the external incision may be pro- 
perly made on one side of the abdomen, are those in 
which a part of the child can be distinctly and promi- 
nently felt, and at that part an incision being made pre- 
vents the danger of wounding any intestine. Mr. Wood 
describes a case in the sixth volume of the Medical 
Journal, in which the nates of the child projected late- 
rally and the incision was made nearly in a transverse 
direction on the left side of the abdomen, beginning at 
the umbilicus. Instead of dividing the placenta, Mr. 
Wood introduced his hand betwixt it and the uterus, and 
extracted the fcetus with ease; a hemorrhage was caused 
by this, which however soon ceased, and not more than 
seven or eight ounces of blood were lost. After the 
uterus was emptied the omentum and intestines protruded 
from the wound but were reduced readily, and the wound 






ELEMENTS OF SURGERY. 459 

was dressed by sutures and adhesive plaster. The wo- 
man, however, died on the fourth day afterwards. 

Mr. Simon, in the Memoirs of the Academy of Surgery, 
relates sixty-four successful cases of the Caesarian opera- 
tion, more than half of which were performed on thirteen 
women, some of whom had undergone the operation once 
or twice, and others five or six times ; one woman had suf- 
fered it seven times and always with success. Mr. Tenon 
counts up sixty- six cases which have occurred at the 
Hotel Dieu in Paris, and other writers have collected a 
considerable number. Baudclocque (by no means par- 
tial to the operation) reports that of one hundred and 
eleven Caesarian operations, performed since the middle 
of the last century, forty-seven or forty-eight have been 
successful.* Mr. Capuron the latest French writer on 
midwifery observes that the Caesarian operation far from 
offering a melancholy catalogue of victims, affords a re- 
source always safe for the infant, and very often for the 
mother, f so that the operation although unquestionably 
hazardous, ought to be performed in all cases where the 
delivery is impracticable by other means, and any hojie 
exists of saving the mother or infant by it. 

In cases of extra-uterine conception the operation as 
already remarked, had in general better be delayed until 
suppuration takes place. 

* In England the Cxsarian section has generally provod fatal, 
f Cours theorique et pratique tPaecoachemens, par J. Capuron. A Paris, 
1811. 



400 ELEMENTS OF SURGERY. 

CHAPTER LXVII. 

On the division of the symphysis pubis. 

Another operation, the consideration of which pro- 
perly belongs to midwifery, is described in several sys- 
tems of surgery, the division of the symphysis pubis for 
the purpose of enlarging the diameter of the pelvis, in 
cases of difficult labours. Mr. Sigault, a French ac- 
coucheur, contrived this operation as a substitute for the 
Caesarian section, than which it is certainly less danger- 
ous and severe ; it was adopted by a majority of the French 
physicians, who proclaimed it one of the most important 
improvements of the healing art. The British generally 
rejected it, and subsequent investigations have proved 
their judgment in great measure correct. 

When the operation is to be performed, Mr. B. Bell 
directs the patient to be placed on her back, upon a table 
of convenient height ; " the pelvis should be elevated with 
two or three pillows, put beneath it, and the legs and arms 
should be secured by assistants. When in this situation, 
the bladder should be emptied by the introduction of a 
catheter, which should be retained in the urethra by one of 
the assistants till the division of the bones is completed. 

" After shaving the pubis, the operator, standing on one 
side of the patient, should, with a longitudinal incision, 
divide the skin and cellular substance covering the pubes 
at their symphysis. The cut should commence at the 
upper edge of these bones, and be continued nearly, but 
not entirely, along their whole breadth: on the bones 
being laid bare, the cartilages by which they are joined 
must be slowly and cautiously divided; and as it is by 
no means hard, it is easily done. Both the teguments 



ElXVrENTS OF SURGERY. 461 

and cartilage may be divided with a firm round-edged 
scalpel of the common form, which is the only instrument 
except the catheter that is necessary in this operation. 
The intention of the catheter is, to point out the course 
of the urethra to the operator ; for it lies so contiguous 
to the pubes at their symphysis as to be in great danger 
of being cut, if this precaution be not attended to; even 
the bladder itself might be injured, were the division of 
the cartilage not conducted with caution : but with due 
attention to these points, and avoiding the total division 
of the soft parts at the under edge of the bones, all risk 
of hurting either the bladder or urethra may be pre- 
vented. 

" On the division of the cartilage being completed, the 
bones recede considerably from each other. To prevent 
any consequences that might ensue from their separating 
forcibly and suddenly, the assistants who have the charge 
of the thighs should be desired to support them, parti- 
cularly towards the end of the operation ; and if a suffi- 
cient opening is not gained in this manner, the thighs 
may afterwards be slowly and gradually separated. 

"The child is now to be delivered in the usual way 
by the vagina, and this being effected, and the placenta 
removed, the bones should be immediately put together, 
and retained as exactly as possible in their situation, by 
the proper application of a cotton or flannel roller round 
the pelvis and thighs ; at the same time that the patient 
should be desired to remain as much as possible in one 
posture. The sore does not require any particular atten- 
tion ; in general it heals easily with light and mild dress- 
ings ; and for the most part the union of the bones is 
completed in the course of the fifth or sixth week. The- 
patient however should not be allowed to walk, or to 
put the body into any posture that might effect an altera- 
tion in the situation of the bones, till nine or ten weeks 
have elapsed." 



4;6£ ELEMENTS OF SURGERY. 

Mr. Baudelocque declares, that he was unable in any 
experiments upon the dead subject, to increase the dia- 
meter of the pelvis by dividing the symphysis pubis, 
more than from three to six lines, (at most half an inch ;) 
on the other baud, some advocates of the operation state, 
that the pelvis is enlarged by it more than two inches. 
Mr. Capuron complaius that the division of the symphy- 
sis pubis has been performed in many cases in which 
the' patient might have been delivered without recourse 
to it, and upon women who had previously borne seve- 
ral children ; an abuse which cannot be too strongly cen- 
sured. Mr. Demangeon has lately published a small 
essay upon this subject, in which he decidedly prefers 
it to the Caesarian section, when one or other of these ope- 
rations must be performed.* I shall not venture an opi- 
nion on the question, but conclude by a caution never to 
perform either of these operations whilst there is the 
least remaining prospect of delivery without them. 

* De Ossium Pubis Synchondrotomia. Parisiis, 1811. 



ELEMENTS OF SURGERY. 463 

CHAPTER LXVITI. 

Of Prolapsus Uteri. 

The uterus losing its natural situation in the pelvis, 
sometimes descends into the vagina, where it may be felt 
forming a pyriform tumour projecting into this passage : 
the os tincse is situated in the centre of the tumour, and 
the finger can readily be passed round it, rendering the 
nature of the case sufficiently evident. A greater de- 
gree of protrusion often takes place, and the uterus is 
found situated exteriorly to the vulva, dragging down the 
vagina, which consequently doubles on itself, and draws 
downward the part of the bladder connected with it. 

The prolapsus when complete, forms a tumour, of an 
oblong and nearly cylindrical form, terminating in a 
narrow circular extremity, in which the os tincse is si- 
tuated ; through this aperture the menses are discharged 
at the usual periods. 

When prolapsus uteri exists in the degree first de- 
scribed, the uterus being situated within the vagina, the 
inconveniences experienced from it are, sensations of great 
weight and uneasiness in the pelvis, sometimes atfecting 
the bladder and kidueys ; these sensations not amount- 
ing to severe pain, are however very distressing, and are 
greatly augmented by exercise. Rest in a horizontal 
posture generally relieves them. 

In a more advanced stage, and greater degree, the 
prolapsus uteri occasions very severe sufferings. The 
symptoms are aggravated, and often very painful. The 
external situation of the uterus in a complete prolapsus, 
exposes it to irritation from various sources ; the urine 
flowing over it, and the friction occasioned by exercise, 
often produce great pain and distress. 



464 elements of surgery. 



TREATMENT. 



When the complaint exists only in a slight degree, 
the uterus may very readily be pushed back with a fin- 
ger to its proper situation, and often indeed resumes it 
when the patient lies in a horizontal posture. The. re- 
duction however is by no means so easy when the uterus 
is completely protruded outside of the vulva. The ab- 
dominal viscera having in some measure accommodated 
themselves to the change in those of the pelvis, do not 
very readily recede to their natural situation, and conse- 
quently preclude the ready return of the uterus : to over- 
come this obstacle, it is necessary to confine the patient 
to a low diet, and to a horizontal posture, for a few 
days, and to administer a cathartic. The warm bath 
may be used if any difficulty of reduction should re- 
main. By the use of these remedies, and the assist- 
ance of the surgeon's fingers, the uterus may be gene- 
rally replaced. It is unnecessary to wait until all inflam- 
mation ceases, because as long as it remains in its unna- 
tural situation, exposed to the external irritations which 
have been mentioned, it will continue somewhat in- 
flamed; at the same time it would be highly improper to 
make any effort at reduction, until the remedies just di- 
rected have had the effect of considerably reducing the 
inflammatory appearance of the uterus. 

In order to retain the uterus in its natural situation, 
an instrument, called a pessary, is to be introduced into 
the vagina. The pessaries formerly employed, were no- 
thing more than masses of wool, of lint, or other soft ma- 
terials, adapted to the shape of the vagina; these are, 
however, at present laid aside, and a variety of substi- 
tutes have been invented. 

A pessary ought to be formed of materials -sufficiently 
firm to support the uterus, and so light as not to descend 



ELEMENTS OF SURGERY. 465 

after it is placed in the vagina. It should be pf a solid 
texture, incapable of imbibing the moisture of the parts, 
because nothing is more offensive than retained animal 
secretions. The form of a pessary is an object of import- 
ance. Dr. Den man directs them to be made globular ; 
Dr. Clarke prefers a flat oval form, with a perforation in 
the centre. Doth these gentlemen direct the pessary to be 
made of box- wood, and Denman's is made hollow, that 
it may be light. The French surgeons form their pessa- 
ries of the same materials as those winch enter into the 
composition of the flexible catheter, their form is a ring, 
and the French pessaries are very light, and to a certain 
degree resist moisture ; but none of these instruments are 
perfect, they all become exceedingly foetid after remain- 
ing a very short time in the vagina. Dr. Physick has had 
pessaries constructed of silver, very thickly gilt. He pre- 
fers the globular form in most cases, and in order to 
have the instrument light, it is made hollow ; two very 
thin hemispheres of silver are soldered together, highly 
polished on the outside, and then coated with gold. The 
silversmiths very easily fabricate such an instrument, 
and it possesses several advantages. The gold is not af- 
fected by the secretions of the vagina, and is the most 
cleanly substance of which the pessary can be made ; the 
objections to forming the instrument entirely of gold, are, 
that it is softer than silver, and consequently must be 
made thicker ; which, in addition to its greater specific 
gravity, would render the pessary too heavy ; it is also 
more expensive. The use of astringent injections has 
been found advantageous incases of prolapsus uteri. 

Prolapsus uteri occurs sometimes during pregnancy, — 
on this subject I refer to the writers on midwifery,— as 
also for an account of the Inversion and Retro-ver- 
sion of the uterus. 

vol. 11. 3 



4,06 ELEMENTS OF SURGERY 

CHAPTER LXIX. 

Of Bandages. 

Bandages are strips of linen, muslin, or flannel, used 
for confining dressings upon wouncls and ulcers, and for 
a variety of surgical purposes. 

The proper application of bandages can only be ac- 
quired by habit, and the best directions on the subject 
will be of no use without practice. In the education of 
a surgeon in Europe, great attention is generally and de- 
servedly paid to instructing him in the dressing of 
wounds, ulcers, fractures, &c. and I lament that opportu- 
nities of acquiring dexterity in this important branch of 
surgery are so little sought after by medical students in 
this country. 

Bandages are formed in general of muslin. This sub- 
stance answers better than linen or flannel. It is suffi- 
ciently strong to confine dressings, and if necessary, to 
compress the parts on which it is applied. It is suffi- 
ciently flexible to accommodate itself to the shape of every 
part of the body, and the roughness of its surface pre- 
vents it from slipping, properties which are combined in 
no substance to so great a degree as in muslin — flannel in 
some cases answers very well, but it retains in general 
too much heat. The muslin used for bandages is the 
coarser kind, and it should be washed before it is used. 
The selvage or stiff margin at the edge of the piece 
should be torn off before the bandage is made. In gene- 
ral it is best to have bandages free from seams. In case 
a long roller is wanted, it should be torn from a piece of 
muslin of the requisite length. 

The mode of applying a bandage must depend en- 






ELEMENTS OF SURGERY. 467 

tirely on the purpose for which it is designed ; where it 
is intended to confine the plasters on a sore, it should bq 
tight enough to effect this object, without any risk of an 
interruption to the circulation of the blood. Inflammation 
and grangrene have often resulted from negligence in this* 
particular. 

In the preceding chapters the chief bandages which 
have been referred to are the roller, and the bandage of 
strips, the invention of which is ascribed to Scultetus. 
The simplicity of modern surgery has rejected a vast va- 
riety of bandages formerly employed, and with the two 
just named, the surgeon is enabled to effect most of those 
purposes for which bandages are necessary. The eighteen- 
tailed bandage is a modification of that of Scultetus 
which I think ought never to be employed, because the 
strips being connected, when one part becomes soiled it 
is requisite to remove the whole, whereas in case one 
or more strips be soiled in the bandage of Scultetus it is 
easy to replace the soiled part. The inconvenience of 
changing the eighteen-tailed bandage is in some cases 
very great, as in compound fractures, because to replace 
it the fractured limb must be completely raised up, 
whereas if the strips be separate they can be changed 
without exposing the patient to this painful resource, by 
pinning the clean strip to the end of each one which is 
to be removed, and drawing it gently under the limb ;— 
by attentions like this, a skilful surgeon is often enabled 
to spare his patient a great deal of suffering, and there- 
fore it ought not to be considered as a subject of trifling 
importance. The principal instances in which the ban- 
dage of strips is proper have been already noticed, but I 
would now recommend it in all cases in which frequent 
examinations of the state of a part may be advantageous, 
and in which the dressings arc to be often changed ; it 
unquestionably in such cases is extremely convenient. 



4,68 ELEMENTS OF SURGERY. 

The roller is a long bandage rolled up for its conve- 
nient application. The part rolled up is called its head, 
and surgeons with more ingenuity than science have com- 
plicated this simple bandage by rolling it with a double 
head, and even with four heads. The simple bandage 
called a single-headed roller may be applied with great 
ease to any purpose which can be accomplished by these 
more complicated methods. The circular, spiral, unit- 
ing, retaining, and expellent bandages are names applied 
to the roller in consequence of the manner in which it is 
applied and of the purposes it is intended to answer. 

The art of applying a roller neatly to every part of the 
body is readily acquired by practice. I shall describe the 
mode of bandaging a leg, and when the student has suffi- 
ciently practiced these directions he will have no difficulty 
in applying a common roller to every other part of the 
body. 

The application of a roller to the leg is to be com- 
menced by a few turns round the foot. The surgeon is 
then to carry the head of the roller over the instep, so as 
to unroll part of the bandage, and apply it just above the 
heel. It is next to be brought over the inner ankle, 
thence over the instep, and under the sole of the foot. 
From this place it is brought again round the foot to the 
outer part of the leg. After which it is to be carried 
round the leg by circular turns, ascending gradually in 
a spiral manner so that each turn of the bandage shall 
cover about one-third of the turn immediately below it. 
The shape of the leg renders this business difficult 
enough to expose the unskilfulness of a surgeon not ac- 
customed to the operation, because when the bandage 
reaches the calf of the leg it becomes necessary to dou- 
ble back the roller to prevent it from becoming uneven, 
or ascending too high, so as to leave part of the skin 
uncovered — a manoeuvre requiring some address. Th : 



ELEMENTS OF SURGERY. 469 

fold or reversing of the roller is to be repeated as often 
as the shape of the limb may render it necessary, and 
the roller is gradually carried up to the knee. 

The head may be bandaged by means of a roller car- 
ried round it in different directions, or by neatly tying a 
handkerchief about it. 

The T bandage which has been more than once re- 
ferred to, is generally used for covering the trunk of the 
body and parts in the vicinity of the organs of genera- 
tion. It consists of two bandages united together at 
right angles. Mr. John Bell remarks that this is the 
peculiar bandage of the body. u If the breast or belly 
be wounded, we make the circular (the part which sur- 
rounds the abdomen) very broad, which serves as the 
proper bandage of the body, and we split the tail part, 
and passing one leg over each side of the neck we pin it 
to the circular, so that it forms a suspensary for the 
main bandage which prevents it from slipping down. 
But if we have a wound or disease on operation near the 
groin or private parts, the tail part becomes then the 
most important part of the bandage ; then the circular is 
smaller and goes round the pelvis while the tail part is 
made very broad. When the disease is in the private 
parts, perineum, or anus, we often split the tail accord- 
ing to circumstances, but when the disease is in one 
groin we generally leave the tail part entire and broad." 

For many judicious remarks on bandages, the reader 
is referred to Bell's Principles of Surgery. 



4/0 ELEMENTS OF SURGERY. 

CHAPTER LXX. 

Of Opening Dead Bodies. 

In a new country new diseases, and old diseases under 
new aspects, may be expected to arise. This affords an 
incentive to the study of morbid anatomy, in addition to 
the numerous advantages which medical science has al- 
ready derived from that source. 

At* instinctive horror of dissecting the dead appears to 
pervade the whole human family, and in civilized coun- 
tries this aversion is so great as to afford a powerful obsta- 
cle to the improvement of the healing art. Enlightened 
reason, however^ is making a rapid improvement in this 
respect, and the importance of dissections begins to be 
acknowledged amongst all ranks of society. In Europe 
the surgeon is frequently requested to examine dead bo- 
dies, and in America permission to do so is not often de- 
nied. It is therefore highly necessary that he should be 
well acquainted with the methods of conducting his ex- 
aminations in the most satisfactory manner. 

Morbid action it has been remarked by Dr. Baillie, 
is a very different thing from morbid structure ; dissection 
which detects the latter, throws no light upon the for- 
mer, and hence the surgeon derives a caution not to 
hazard an opinion as to changes of structure, before 
death, unless there be very palpable evidence of the fact. 
I have examined a body in which there was almost every 
diagnostic symptom of an organic affection of the heart, 
and all these symptoms probably arose from dyspepsia, 
as there was nothing unusual in any of the viscera. 

Another introductory remark I beg leave to offer, which 
is, that to ascertain the effects of disease on the animal 



} 






ELEMENTS OF SURGERY. 4^1 

structure, it is essential that its healthy condition be well 
understood. No person therefore but an anatomist, 
one who is acquainted with the natural appearances of 
the various parts of the body, can be competent to such 
investigations. To illustrate this, it may not be impro- 
per to men-ion one or two very common mistakes to 
which the unpracticed dissector is liable. He confounds 
coagula in various places with polypi. A coagulum in 
the heart or larger vessels is in his view a polypus. He 
mistakes natural, for diseased productions ; the plexus 
choroides I have known to be magnified into a morbid 
adhesion ; the glands of Pacchioni are sometimes consi- 
dered as scirrhous indurations, &c. But perhaps a more 
frequent mistake than any other has arisen from want of 
attention to the position of the body. The blood never 
fails to settle and stagnate in depending parts, and hence 
in general the back of the patient becomes purple and 
black, resembling those petechias which are symptomatic 
of malignant fever. A young gentleman once supposed he 
had discovered a symptom of yellow fever which had es- 
caped the notice of all the writers on the subject, a gan- 
grene of the scrotum ! His discovery like many other 
discoveries depended on his ignorance of common ap- 
pearances. The scrotum being a depending part, is often 
black from stagnated blood. 

The surgeon is occasionally called on by the officers 
of government to ascertain by dissection the cause of 
death. In these cases, and in every instance in which 
his opinion can affect the life of a suspected criminal, too 
much caution cannot be urged upon him. 

Very distressing accidents having sometimes arisen 
from wounds or punctures of the fingers in dissections, 
the surgeon should be careful to avoid such injuries. 

The instruments necessary in the examination of dead 
bodies are scalpels, a saw, and strong elevator or chisel. 



472 ELEMENTS OF SURGERY. 

needles, ligatures, and sponges. Care should be taken 
to avoid soiling the shroud and coverings of the subject, 
and the utmost decency should mark the whole operation, 
every unnecessary exposure being carefully avoided. 

It is proper to make the external incision in such situ- 
ations as not to disfigure the corpse — of course in parts 
concealed from view. 

OP OPENING THE HEAD. 

When the head is to be opened for anatomical inspec- 
tion, it is to be elevated on a block placed behind the 
neck, and firmly held in that position by an assistant. 

An incision should be made through the scalp, from 
one ear to the other, and the scalp dissected and reverted 
forward and backward so as to expose the cranium ; the 
temporal muscle is to be divided where it covers the tem- 
poral bone in such a manner that it may not interfere with 
the action of the saw. The cranium is next to be divided 
with a common amputating saw as nearly as possible in a 
straight line, beginning just above the frontal sinuses, and 
continued horizontally around the cranium ; the dura 
mater should be avoided as carefully as possible, but it is 
scarcely practicable to prevent its being injured in some 
places. 

With the elevator, or what is better a strong chisel, the 
cranium is to be separated and the external surface of the 
dura mater examined. This membrane is to be next 
divided in a line corresponding with that by which the 
bone had been sawed ; at the falciform process it will 
adhere, but the brain will become exposed by lift- 
ing up the lateral portions of the dura mater, and the pia 
mater can then be examined ; the substance of the brain 
and its ventricles are best exposed by horizontal sec- 
tions, and if necessary, the falx can afterwards be cut 
loose, and the whole contents of the cranium inspected. 



ELEMENTS OP SURGERY. 4^3 

The blood being removed with a sponge, the brain is 
to be replaced, the cranium laid over it, the scalp drawn 
into its natural situation, and by means of an armed 
needle it is to be there retained by the common glover's 
suture. " 

OP OPENING THE THORAX AND ABDOMEN. 

When the great cavities are to be examined, an incision 
is to be made through the integuments from the top of the 
sternum to the navel, and from thence continued to the 
anterior superior spinous process of each os ilium, or 
rather below them.* The integuments and muscles 
are then to be dissected from the thorax until the car- 
tilages of the ribs are exposed, and these are to be di- 
vided near the ribs by a strong knife; the diaphragm is 
to be separated beneath, the lower part of the sternum is 
to be elevated, the mediastinum cut from it, and an inci- 
sion is now to be made across the upper end of the ster- 
nium in order to divide the strong ligamentous matter 
which gives it .strength ; when this is done it can easily 
be broken through and turned upwards in such a manner 
as to expose the contents of the thorax. 

If, however, the upper part of the thorax is to be care- 
fully examined, it will be found more convenient to sepa- 
rate the cordiform portion of the sternum from the clavi- 
cles, and in this manner to expose the whole cavity of 
the thorax. In opening the abdomen some caution is ne- 
cessary in dividing the peritoneum, because when the in- 
testines are distended with flatus they are very apt to be 
opened unnecessarily by a hasty or careless incision ; 
when the peritoneum is punctured at one place, two fin- 
ders should be introduced into the aperture, and the in- 

• The crucial incision usually made, occasions more exposure than is ncce*- 
s^rv and therefore should be laid aside. 

VOL. II. 3p 



474 KL 

cision completed by cutting outward between these two 
fingers. 

The cavities being in this manner laid open, their re- 
spective viscera will be subjected to inspection, and this 
being completed, ligatures are to be tied round any of 
the viscera or larger vessels which may have been di- 
vided, and the parts replaced in their natural situation, 
are to be kept so by the glover's suture. When it is in- 
tended to remove the morbid parts in order to preserve 
them, great caution is necessary in the dissection, and it 
is best to take along with the affected parts some portion 
of the surrounding substance which can be subsequently 
dissected off with neatness and caution. 

In examining the throat and fauces an incision 
should be made from the chin to the sternum ; and the 
pharynx, larynx, tongue, and parts adjacent, are to be 
brought out and inspected at this incision, after which 
they are easily replaced, and the skin being neatly closed 
with the common suture, the body will not be disfigured 
by the examination. 

In the dissection of other parts the best general rule 
which can be given, is to make incisions sufficiently ex- 
tensive to answer the end, and to make them as much as 
possible in places not exposed to view. 

I shall conclude this subject by remarking that no 
anatomical investigation should be commenced until the 
death of the subject is absolutely certain. The signs of 
death are foreign from my present subject, but coldness 
and putrefaction are among those which should be pre- 
sent before any human corpse is subjected to dissection. 



THE END. 



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